Maternity and pediatric nursing. [2ed] 9781609137472, 1609137477

Table of contents :
Cover
Title Page
Copyright
Dedication
Acknowledgments
About the Authors
Reviewers to the Second Edition
Preface
ORGANIZATION
RECURRING FEATURES
Contents
Contents in Brief
Unit One: Introduction to Maternity and Pediatric Nursing
CHAPTER 1: Perspectives on Maternal and Child Health Care
KEY TERMS
Learning Objectives
HISTORICAL DEVELOPMENT
The History of Maternal and Newborn Health and Health Care
The History of Child Health and Child Health Care
Evolution of Maternal and Newborn Nursing
Evolution of Pediatric Nursing
HEALTH STATUS OF WOMEN AND CHILDREN
Mortality
Childhood Mortality
Morbidity
FACTORS AFFECTING MATERNAL AND CHILD HEALTH
Family
Genetics
Society
Culture
Health Status and Lifestyle
Access to Health Care
Improvements in Diagnosis and Treatments
Empowerment of Health Care Consumers
BARRIERS TO HEALTH CARE
Finances
Sociocultural Barriers
Health Care Delivery System Barriers
LEGAL AND ETHICAL ISSUES IN MATERNAL AND CHILD HEALTH CARE
Abortion
Substance Abuse
Intrauterine Therapy
Maternal–Fetal Conflict
Stem Cell Research
Umbilical Cord Blood Banking
Informed Consent
Assent
Refusal of Medical Treatment
Advance Directives
Client Rights
Confidentiality
IMPLICATIONS FOR NURSES
KEY CONCEPTS
References
CHAPTER WORKSHEET
CHAPTER 2: Core Concepts of Maternal and Child Health Care and Community-Based Care
KEY TERMS
Learning Objectives
CORE CONCEPTS OF MATERNAL AND CHILD HEALTH NURSING
Family-Centered Care
Evidence-Based Care
Collaborative Care
Atraumatic Pediatric Care
Communication
Education
Discharge Planner and Case Manager
Client Advocate and Resource Manager
Preventative Care
Culturally Competent Nursing Care
Complementary and Alternative Medicine
COMMUNITY-BASED CARE
Community Health Nursing
Community-Based Nursing
Shift in Responsibilities From Hospital-Based to Community-Based Nursing
Community-Based Nursing Interventions
Community-Based Nursing Challenges
Community-Based Nursing Care Settings for Women and Children
KEY CONCEPTS
References
CHAPTER WORKSHEET
Unit Two: Women’s Health Throughout the Life Span
CHAPTER 3: Anatomy and Physiology of the Reproductive System
KEY TERMS
Learning Objectives
FEMALE REPRODUCTIVE ANATOMY AND PHYSIOLOGY
External Female Reproductive Organs
Internal Female Reproductive Organs
Breasts
Female Sexual Response
THE FEMALE REPRODUCTIVE CYCLE
Menstruation
Reproductive Cycle
MALE REPRODUCTIVE ANATOMY AND PHYSIOLOGY
External Male Reproductive Organs
Internal Male Reproductive Organs
Male Sexual Response
KEY CONCEPTS
References
CHAPTER WORKSHEET
CHAPTER 4: Common Reproductive Issues
KEY TERMS
Learning Objectives
MENSTRUAL DISORDERS
Amenorrhea
Dysmenorrhea
Dysfunctional Uterine Bleeding
Premenstrual Syndrome
Endometriosis
INFERTILITY
Cultural Considerations
Etiology and Risk Factors
Therapeutic Management
Nursing Assessment
Nursing Management
CONTRACEPTION
Types of Contraceptive Methods
Nursing Management of the Woman Choosing a Contraceptive Method
Nursing Assessment
Nursing Diagnoses
Nursing Interventions
ABORTION
Surgical Abortion
Medical Abortion
MENOPAUSAL TRANSITION
Therapeutic Management
Nursing Assessment
Nursing Management
KEY CONCEPTS
References
CHAPTER WORKSHEET
CHAPTER 5: Sexually Transmitted Infections
KEY TERMS
Learning Objectives
SEXUALLY TRANSMITTED INFECTIONS AND ADOLESCENTS
Nursing Assessment
Nursing Management
INFECTIONS CHARACTERIZED BY VAGINAL DISCHARGE
Genital/Vulvovaginal Candidiasis (VVC)
Trichomoniasis
Bacterial Vaginosis
INFECTIONS CHARACTERIZED BY CERVICITIS
Chlamydia
Gonorrhea
INFECTIONS CHARACTERIZED BY GENITAL ULCERS
Genital Herpes Simplex
Syphilis
Pelvic Inflammatory Disease
VACCINE-PREVENTABLE STIs
Human Papillomavirus
Hepatitis A and B
Hepatitis C
ECTOPARASITIC INFECTIONS
HUMAN IMMUNODEFICIENCY VIRUS (HIV)
HIV and Adolescents
Clinical Manifestations
Diagnosis
Therapeutic Management
Nursing Management
PREVENTING SEXUALLY TRANSMITTED INFECTIONS
Behavior Modification
Contraception
KEY CONCEPTS
References
CHAPTER WORKSHEET
CHAPTER 6: Disorders of the Breasts
KEY TERMS
Learning Objectives
BENIGN BREAST DISORDERS
Fibrocystic Breast Changes
Fibroadenomas
Mastitis
MALIGNANT BREAST DISORDERS
Pathophysiology
Risk Factors
Diagnosis
Therapeutic Management
NURSING PROCESS FOR THE CLIENT WITH BREAST CANCER
Breast Cancer Screening
Nutrition
KEY CONCEPTS
References
CHAPTER WORKSHEET
CHAPTER 7: Benign Disorders of the Female Reproductive Tract
KEY TERMS
Learning Objectives
PELVIC SUPPORT DISORDERS
Pelvic Organ Prolapse
Urinary Incontinence
BENIGN GROWTHS
Polyps
Uterine Fibroids
Genital Fistulas
Bartholin’s Cysts
Ovarian Cysts
KEY CONCEPTS
References
CHAPTER WORKSHEET
CHAPTER 8: Cancers of the Female Reproductive Tract
KEY TERMS
Learning Objectives
NURSING PROCESS OVERVIEW FOR THE WOMAN WITH CANCER OF THE REPRODUCTIVE TRACT
OVARIAN CANCER
Pathophysiology
Screening and Diagnosis
Therapeutic Management
Nursing Assessment
Nursing Management
Endometrial Cancer
Cervical Cancer
Vaginal Cancer
Vulvar Cancer
KEY CONCEPTS
References
CHAPTER WORKSHEET
CHAPTER 9: Violence and Abuse
KEY TERMS
Learning Objectives
INTIMATE PARTNER VIOLENCE
Incidence
Background
Characteristics of Intimate Partner Violence
Types of Abuse
Myths and Facts About Intimate Partner Violence
Abuse Profiles
Violence Against Pregnant Women
Violence Against Older Women
Nursing Management of Intimate Partner Violence Victims
SEXUAL VIOLENCE
Sexual Abuse
Incest
Rape
Female Genital Cutting
Human Trafficking
SUMMARY
KEY CONCEPTS
References
CHAPTER WORKSHEET
Unit Three: Pregnancy
CHAPTER 10: Fetal Development and Genetics
KEY TERMS
Learning Objectives
FETAL DEVELOPMENT
Preembryonic Stage
Embryonic Stage
Fetal Stage
Fetal Circulation
GENETICS
Advances in Genetics
Inheritance
Patterns of Inheritance for Genetic Disorders
Chromosomal Abnormalities
GENETIC EVALUATION AND COUNSELING
Nursing Roles and Responsibilities
KEY CONCEPTS
References
CHAPTER WORKSHEET
CHAPTER 11: Maternal Adaptation During Pregnancy
KEY TERMS
Learning Objectives
SIGNS AND SYMPTOMS OF PREGNANCY
Subjective (Presumptive) Signs
Objective (Probable) Signs
Positive Signs
PHYSIOLOGIC ADAPTATIONS DURING PREGNANCY
Reproductive System Adaptations
General Body System Adaptations
CHANGING NUTRITIONAL NEEDS OF PREGNANCY
Nutritional Requirements During Pregnancy
Maternal Weight Gain
Nutrition Promotion
Special Nutritional Considerations
PSYCHOSOCIAL ADAPTATIONS DURING PREGNANCY
Maternal Emotional Responses
Maternal Role Tasks
Pregnancy and Sexuality
Pregnancy and the Partner
Pregnancy and Siblings
KEY CONCEPTS
References
CHAPTER WORKSHEET
CHAPTER 12: Nursing Management During Pregnancy
KEY TERMS
Learning Objectives
PRECONCEPTION CARE
Risk Factors for Adverse Pregnancy Outcomes
Nursing Management
THE FIRST PRENATAL VISIT
Comprehensive Health History
Physical Examination
Laboratory Tests
FOLLOW-UP VISITS
Follow-Up Visit Intervals and Assessments
Fundal Height Measurement
Fetal Movement Determination
Fetal Heart Rate Measurement
Teaching About the Danger Signs of Pregnancy
ASSESSMENT OF FETAL WELL-BEING
Ultrasonography
Doppler Flow Studies
Alpha-Fetoprotein Analysis
Marker Screening Tests
Nuchal Translucency Screening
Amniocentesis
Chorionic Villus Sampling
Percutaneous Umbilical Blood Sampling
Nonstress Test
Contraction Stress Test
Biophysical Profile
NURSING MANAGEMENT FOR THE COMMON DISCOMFORTS OF PREGNANCY
First-Trimester Discomforts
Second-Trimester Discomforts
Third-Trimester Discomforts
NURSING MANAGEMENT TO PROMOTE SELF-CARE
Personal Hygiene
Clothing
Exercise
Sleep and Rest
Sexual Activity and Sexuality
Employment
Travel
Immunizations and Medications
NURSING MANAGEMENT TO PREPARE THE WOMAN AND HER PARTNER FOR LABOR, BIRTH, AND PARENTHOOD
Childbirth Education Classes
Nursing Management and Childbirth Education
Options for Birth Settings and Care Providers
Preparation for Breast-Feeding or Bottle-Feeding
Final Preparation for Labor and Birth
KEY CONCEPTS
References
CHAPTER WORKSHEET
Unit Four: Labor and Birth
CHAPTER 13: Labor and Birth Process
KEY TERMS
Learning Objectives
INITIATION OF LABOR
PREMONITORY SIGNS OF LABOR
Cervical Changes
Lightening
Increased Energy Level
Bloody Show
Braxton Hicks Contractions
Spontaneous Rupture of Membranes
TRUE VERSUS FALSE LABOR
FACTORS AFFECTING THE LABOR PROCESS
Passageway
Passenger
Powers
Position (Maternal)
Psychological Response
Philosophy
Partners
Patience
Patient (Client) Preparation
Pain Management
PHYSIOLOGIC RESPONSES TO LABOR
Maternal Responses
Fetal Responses
STAGES OF LABOR
First Stage
Second Stage
Third Stage
Fourth Stage
KEY CONCEPTS
References
CHAPTER WORKSHEET
CHAPTER 14: Nursing Management During Labor and Birth
KEY TERMS
Learning Objectives
MATERNAL ASSESSMENT DURING LABOR AND BIRTH
Vaginal Examination
Assessing Uterine Contractions
Performing Leopold’s Maneuvers
FETAL ASSESSMENT DURING LABOR AND BIRTH
Analysis of Amniotic Fluid
Analysis of the FHR
Other Fetal Assessment Methods
PROMOTING COMFORT AND PROVIDING PAIN MANAGEMENT DURING LABOR
Nonpharmacologic Measures
Pharmacologic Measures
NURSING CARE DURING LABOR AND BIRTH
Nursing Care During the First Stage of Labor
Nursing Management During the Second Stage of Labor
Nursing Management During the Third Stage of Labor
Nursing Management During the Fourth Stage of Labor
KEY CONCEPTS
References
CHAPTER WORKSHEET
Unit Five: Postpartum Period
CHAPTER 15: Postpartum Adaptations
KEY TERMS
Learning Objectives
MATERNAL PHYSIOLOGIC ADAPTATIONS
Reproductive System Adaptations
Cardiovascular System Adaptations
Urinary System Adaptations
Gastrointestinal System Adaptations
Musculoskeletal System Adaptations
Integumentary System Adaptations
Respiratory System Adaptations
Endocrine System Adaptations
CULTURAL CONSIDERATIONS FOR THE POSTPARTUM PERIOD
PSYCHOLOGICAL ADAPTATIONS
Parental Attachment Behaviors
Maternal Psychological Adaptations
Partner Psychological Adaptations
KEY CONCEPTS
References
CHAPTER WORKSHEET
CHAPTER 16: Nursing Management During the Postpartum Period
KEY TERMS
Learning Objectives
SOCIAL SUPPORT AND CULTURAL CONSIDERATIONS
NURSING ASSESSMENT
Vital Signs Assessment
Physical Assessment
Psychosocial Assessment
NURSING INTERVENTIONS
Providing Optimal Cultural Care
Promoting Comfort
Assisting With Elimination
Promoting Activity, Rest, and Exercise
Preventing Stress Incontinence
Assisting With Self-Care Measures
Ensuring Safety
Counseling About Sexuality and Contraception
Promoting Maternal Nutrition
Supporting the Woman’s Choice of Infant Feeding Method
Teaching About Breast Care
Promoting Family Adjustment and Well-Being
Preparing for Discharge
KEY CONCEPTS
References
CHAPTER WORKSHEET
Unit Six: The Newborn
CHAPTER 17: Newborn Transitioning
KEY TERMS
Learning Objectives
PHYSIOLOGIC TRANSITIONING
Cardiovascular System Adaptations
Respiratory System Adaptations
Body Temperature Regulation
Hepatic System Function
Gastrointestinal System Adaptations
Renal System Changes
Immune System Adaptations
Integumentary System Adaptations
Neurologic System Adaptations
BEHAVIORAL ADAPTATIONS
Behavioral Patterns
Newborn Behavioral Responses
KEY CONCEPTS
References
CHAPTER WORKSHEET
CHAPTER 18: Nursing Management of the Newborn
KEY TERMS
Learning Objectives
NURSING MANAGEMENT DURING THE IMMEDIATE NEWBORN PERIOD
Assessment
Nursing Interventions
NURSING MANAGEMENT DURING THE EARLY NEWBORN PERIOD
Assessment
Nursing Interventions
KEY CONCEPTS
References
CHAPTER WORKSHEET
Unit Seven: Childbearing at Risk
CHAPTER 19: Nursing Management of Pregnancy at Risk: Pregnancy-Related Complications
KEY TERMS
Learning Objectives
BLEEDING DURING PREGNANCY
Spontaneous Abortion
Ectopic Pregnancy
Gestational Trophoblastic Disease
Cervical Insufficiency
Placenta Previa
Abruptio Placentae
Placenta Accreta
HYPEREMESIS GRAVIDARUM
Pathophysiology
Therapeutic Management
Nursing Assessment
Nursing Management
HYPERTENSIVE DISORDERS OF PREGNANCY
Chronic Hypertension
Gestational Hypertension
Preeclampsia and Eclampsia
HELLP SYNDROME
Pathophysiology
Therapeutic Management
Nursing Assessment
Nursing Management
GESTATIONAL DIABETES
BLOOD INCOMPATIBILITY
Pathophysiology
Nursing Assessment
Nursing Management
AMNIOTIC FLUID IMBALANCES
Hydramnios
Oligohydramnios
MULTIPLE GESTATION
Therapeutic Management
Nursing Assessment
Nursing Management
PREMATURE RUPTURE OF MEMBRANES
Therapeutic Management
Nursing Assessment
Nursing Management
KEY CONCEPTS
References
CHAPTER WORKSHEET
CHAPTER 20: Nursing Management of the Pregnancy at Risk: Selected Health Conditions and Vulnerable Populations
KEY TERMS
Learning Objectives
DIABETES MELLITUS
Pathophysiology
Screening
Therapeutic Management
Nursing Assessment
Nursing Management
CARDIOVASCULAR DISORDERS
Congenital and Acquired Heart Disease
Chronic Hypertension
RESPIRATORY CONDITIONS
Asthma
Tuberculosis
HEMATOLOGIC CONDITIONS
Iron-Deficiency Anemia
Thalassemia
Sickle Cell Anemia
AUTOIMMUNE DISORDERS
Systemic Lupus Erythematosus
Multiple Sclerosis
Rheumatoid Arthritis
INFECTIONS
Cytomegalovirus
Rubella
Herpes Simplex Virus
Hepatitis B Virus
Varicella Zoster Virus
Parvovirus B19
Group B Streptococcus
Toxoplasmosis
Women Who Are HIV Positive
VULNERABLE POPULATIONS
Pregnant Adolescent
The Pregnant Woman Over Age 35
The Obese Pregnant Woman
The Pregnant Woman with Substance Abuse
KEY CONCEPTS
References
CHAPTER WORKSHEET
CHAPTER 21: Nursing Management of Labor and Birth at Risk
KEY TERMS
Learning Objectives
DYSTOCIA
Problems with the Powers
Problems with the Passenger
Problems with the Passageway
Problems with the Psyche
PRETERM LABOR
Therapeutic Management
Nursing Assessment
Nursing Management
PROLONGED PREGNANCY
Nursing Assessment
Nursing Management
WOMEN REQUIRING LABOR INDUCTION AND AUGMENTATION
Therapeutic Management
Nursing Assessment
Nursing Management
VAGINAL BIRTH AFTER CESAREAN
INTRAUTERINE FETAL DEMISE
Nursing Assessment
Nursing Management
WOMEN EXPERIENCING AN OBSTETRIC EMERGENCY
Umbilical Cord Prolapse
Placenta Previa
Placental Abruption
Uterine Rupture
Amniotic Fluid Embolism
WOMEN REQUIRING BIRTH-RELATED PROCEDURES
Amnioinfusion
Forceps- or Vacuum-Assisted Birth
Cesarean Birth
KEY CONCEPTS
References
CHAPTER WORKSHEET
CHAPTER 22: Nursing Management of the Postpartum Woman at Risk
KEY TERMS
Learning Objectives
POSTPARTUM HEMORRHAGE
Pathophysiology
Therapeutic Management
Nursing Assessment
Nursing Management
THROMBOEMBOLIC CONDITIONS
Pathophysiology
Nursing Assessment
Nursing Management
POSTPARTUM INFECTION
Metritis
Wound Infections
Urinary Tract Infections
Mastitis
POSTPARTUM AFFECTIVE DISORDERS
Postpartum or Baby Blues
Postpartum Depression
Postpartum Psychosis
KEY CONCEPTS
References
CHAPTER WORKSHEET
Unit Eight: The Newborn at Risk
CHAPTER 23: Nursing Care of the Newborn with Special Needs
KEY TERMS
Learning Objectives
BIRTHWEIGHT VARIATIONS
Small-For-Gestational-Age Newborns
Large-For-Gestational-Age Newborns
GESTATIONAL AGE VARIATIONS
Postterm Newborn
Preterm Newborn
Late Preterm Newborn (“Near Term”)
KEY CONCEPTS
References
CHAPTER WORKSHEET
CHAPTER 24: Nursing Management of the Newborn at Risk: Acquired and Congenital Newborn Conditions
KEY TERMS
Learning Objectives
ACQUIRED DISORDERS
Perinatal Asphyxia
Transient Tachypnea of the Newborn
Respiratory Distress Syndrome
Meconium Aspiration Syndrome
Persistent Pulmonary Hypertension of the Newborn
Intraventricular Hemorrhage
Necrotizing Enterocolitis
Infants of Diabetic Mothers
Birth Trauma
Newborns of Substance-Abusing Mothers
Hyperbilirubinemia
Newborn Infections
CONGENITAL CONDITIONS
Esophageal Atresia and Tracheoesophageal Fistula
Omphalocele and Gastroschisis
Anorectal Malformations
Bladder Exstrophy
KEY CONCEPTS
References
CHAPTER WORKSHEET
Unit Nine: Health Promotion of the Growing Child and Family
CHAPTER 25: Growth and Development of the Newborn and Infant
KEY TERMS
Learning Objectives
GROWTH AND DEVELOPMENT OVERVIEW
Physical Growth
Organ System Maturation
Psychosocial Development
Cognitive Development
Motor Skill Development
Sensory Development
Communication and Language Development
Social and Emotional Development
Cultural Influences on Growth and Development
THE NURSE’S ROLE IN NEWBORN AND INFANT GROWTH AND DEVELOPMENT
NURSING PROCESS OVERVIEW
Promoting Healthy Growth and Development
Addressing Common Developmental Concerns
KEY CONCEPTS
References
CHAPTER WORKSHEET
CHAPTER 26: Growth and Development of the Toddler
KEY TERMS
Learning Objectives
GROWTH AND DEVELOPMENT OVERVIEW
Physical Growth
Organ System Maturation
Psychosocial Development
Motor Skill Development
Sensory Development
Communication and Language Development
Emotional and Social Development
Moral and Spiritual Development
Cultural Influences on Growth and Development
THE NURSE’S ROLE IN TODDLER GROWTH AND DEVELOPMENT
NURSING PROCESS OVERVIEW
Promoting Healthy Growth and Development
Addressing Common Developmental Concerns
KEY CONCEPTS
References
CHAPTER WORKSHEET
CHAPTER 27: Growth and Development of the Preschooler
KEY TERMS
Learning Objectives
GROWTH AND DEVELOPMENT OVERVIEW
Physical Growth
Organ System Maturation
Psychosocial Development
Cognitive Development
Moral and Spiritual Development
Motor Skill Development
Sensory Development
Communication and Language Development
Emotional and Social Development
Cultural Influences on Growth and Development
THE NURSE’S ROLE IN PRESCHOOL GROWTH AND DEVELOPMENT
NURSING PROCESS OVERVIEW
Promoting Healthy Growth and Development
Addressing Common Developmental Concerns
KEY CONCEPTS
References
CHAPTER WORKSHEET
CHAPTER 28: Growth and Development of the School-Age Child
KEY TERMS
Learning Objectives
GROWTH AND DEVELOPMENT OVERVIEW
Physical Growth
Organ Systems Maturation
Psychosocial Development
Cognitive Development
Moral and Spiritual Development
Motor Skill Development
Sensory Development
Communication and Language Development
Emotional and Social Development
Cultural Influences on Growth and Development
THE NURSE’S ROLE IN SCHOOL-AGE GROWTH AND DEVELOPMENT
NURSING PROCESS OVERVIEW
Promoting Healthy Growth and Development
Addressing Common Developmental Concerns
KEY CONCEPTS
Reference
CHAPTER WORKSHEET
CHAPTER 29: Growth and Development of the Adolescent
KEY TERMS
Learning Objectives
GROWTH AND DEVELOPMENT OVERVIEW
Physiologic Changes Associated with Puberty
Physical Growth
Organ System Maturation
Psychosocial Development
Cognitive Development
Moral and Spiritual Development
Motor Skill Development
Communication and Language Development
Emotional and Social Development
Cultural Influences on Growth and Development
THE NURSE'S ROLE IN ADOLESCENT GROWTH AND DEVELOPMENT
NURSING PROCESS OVERVIEW
Promoting Healthy Growth and Development
Addressing Common Developmental Concerns
KEY CONCEPTS
References
CHAPTER WORKSHEET
Unit Ten: Children and Their Families
CHAPTER 30: Atraumatic Care of Children and Families
KEY TERMS
Learning Objectives
PREVENTING/MINIMIZING PHYSICAL STRESSORS
Utilizing the Child Life Specialist
Minimizing Physical Stress During Procedures
PREVENTING OR MINIMIZING CHILD AND FAMILY SEPARATION: PROVIDING CLIENT- AND FAMILY-CENTERED CARE
PROMOTING A SENSE OF CONTROL
Enhancing Communication
Teaching Children and Families
References
CHAPTER WORKSHEET
CHAPTER 31: Health Supervision
KEY TERMS
Learning Objectives
PRINCIPLES OF HEALTH SUPERVISION
Wellness
Medical Home
Partnerships
Special Issues in Health Supervision
COMPONENTS OF HEALTH SUPERVISION
Developmental Surveillance and Screening
Injury and Disease Prevention
Health Promotion
KEY CONCEPTS
References
CHAPTER WORKSHEET
CHAPTER 32: Health Assessment of Children
KEY TERMS
Learning Objectives
HEALTH HISTORY
Preparing for the Health History
Performing a Health History
PHYSICAL EXAMINATION
Preparing for the Physical Examination
Steps of the Physical Examination
Performing a Physical Examination
KEY CONCEPTS
References
CHAPTER WORKSHEET
CHAPTER 33: Caring for Children in Diverse Settings
KEY TERMS
Learning Objectives
HOSPITALIZATION IN CHILDHOOD
Children’s Reactions to Hospitalization
Factors Affecting Children’s Reaction to Hospitalization
Family’s Reactions to the Child’s Hospitalization
The Nurse’s Role in Caring for the Hospitalized Child
COMMUNITY CARE IN CHILDHOOD
Community-Based Nursing Settings
KEY CONCEPTS
References
CHAPTER WORKSHEET
CHAPTER 34: Caring for the Special Needs Child
KEY TERMS
Learning Objectives
THE MEDICALLY FRAGILE CHILD
Impact of the Problem
Effects of Special Needs on the Child
Effects on the Family
Nursing Management of the Medically Fragile Child and Family
THE DYING CHILD
End-of-Life Decision Making
Nursing Management of the Dying Child
KEY CONCEPTS
References
CHAPTER WORKSHEET
CHAPTER 35: Key Pediatric Nursing Interventions
KEY TERMS
Learning Objectives
MEDICATION ADMINISTRATION
Differences in Pharmacodynamics and Pharmacokinetics
Developmental Issues and Concerns
Determination of Correct Dose
Oral Administration
Rectal Administration
Ophthalmic Administration
Otic Administration
Nasal Administration
Intramuscular Administration
Subcutaneous and Intradermal Administration
Intravenous Administration
Providing Atraumatic Care
Educating the Child and Parents
Preventing Medication Errors
INTRAVENOUS THERAPY
Sites
Equipment
Inserting Peripheral IV Access Devices
IV Fluid Administration
Preventing Complications
Discontinuing the IV Device
PROVIDING NUTRITIONAL SUPPORT
Enteral Nutrition
Parenteral Nutrition
KEY CONCEPTS
References
CHAPTER WORKSHEET
CHAPTER 36: Pain Management in Children
KEY TERMS
Learning Objectives
PHYSIOLOGY OF PAIN
Transduction
Transmission
Perception
Modulation
TYPES OF PAIN
Classification by Duration
Classification by Etiology
Classification by Source or Location
FACTORS INFLUENCING PAIN
Age and Gender
Cognitive Level
Temperament
Previous Pain Experiences
Family and Culture
Situational Factors
DEVELOPMENTAL CONSIDERATIONS
Infants
Toddlers
Preschoolers
School-Age Children
Adolescents
COMMON FALLACIES AND MYTHS ABOUT PAIN IN CHILDREN
NURSING PROCESS OVERVIEW FOR THE CHILD IN PAIN
MANAGEMENT OF PAIN
Nonpharmacologic Management
Pharmacologic Management
Management of Procedure-Related Pain
Management of Chronic Pain
KEY CONCEPTS
References
CHAPTER WORKSHEET
Unit Eleven: Nursing Care of the Child With a Health Disorder
CHAPTER 37: Nursing Care of the Child With an Infectious or Communicable Disorder
KEY TERMS
Learning Objectives
INFECTIOUS PROCESS
Fever
Stages of Infectious Disease
Chain of Infection
Preventing the Spread of Infection
VARIATIONS IN PEDIATRIC ANATOMY AND PHYSIOLOGY
COMMON MEDICAL TREATMENTS
NURSING PROCESS OVERVIEW FOR THE CHILD WITH AN INFECTIOUS OR COMMUNICABLE DISORDER
SEPSIS
Pathophysiology
Therapeutic Management
Nursing Assessment
Nursing Management
BACTERIAL INFECTIONS
Community-Acquired Methicillin-Resistant Staphylococcus Aureus
Scarlet Fever
Diphtheria
Pertussis
Tetanus
VIRAL INFECTIONS
Viral Exanthems
Mumps
ZOONOTIC INFECTIONS
Cat Scratch Disease
Rabies
VECTOR-BORNE INFECTIONS
Lyme Disease
Rocky Mountain Spotted Fever
PARASITIC AND HELMINTHIC INFECTIONS
Nursing Assessment and Management
SEXUALLY TRANSMITTED INFECTIONS
KEY CONCEPTS
References
CHAPTER WORKSHEET
CHAPTER 38: Nursing Care of the Child With a Neurologic Disorder
KEY TERMS
Learning Objectives
VARIATIONS IN PEDIATRIC ANATOMY AND PHYSIOLOGY
Brain and Spinal Cord Development
Nervous System
Head Size
COMMON MEDICAL TREATMENTS
NURSING PROCESS OVERVIEW FOR THE CHILD WITH A NEUROLOGIC DISORDER
SEIZURE DISORDERS
Epilepsy
Febrile Seizures
Neonatal Seizures
STRUCTURAL DEFECTS
Neural Tube Defects
Microcephaly
Arnold-Chiari Malformation
Intracranial Arteriovenous Malformation
Craniosynostosis
Positional Plagiocephaly
INFECTIOUS DISORDERS
Bacterial Meningitis
Aseptic Meningitis
Encephalitis
Reye Syndrome
TRAUMA
Head Trauma
Nonaccidental Head Trauma
Near Drowning
BLOOD FLOW DISRUPTION
Cerebral Vascular Disorders (Stroke)
CHRONIC DISORDERS
Headaches
Breath Holding
KEY CONCEPTS
References
CHAPTER WORKSHEET
CHAPTER 39: Nursing Care of the Child With a Disorder of the Eyes or Ears
KEY TERMS
Learning Objectives
VARIATIONS IN PEDIATRIC ANATOMY AND PHYSIOLOGY
Eyes
Ears
COMMON MEDICAL TREATMENTS
NURSING PROCESS OVERVIEW FOR THE CHILD WITH A DISORDER OF THE EYES OR EARS
INFECTIOUS AND INFLAMMATORY DISORDERS OF THE EYES
Conjunctivitis
Nasolacrimal Duct Obstruction
Eyelid Disorders
Periorbital Cellulitis
EYE INJURIES
Nursing Assessment
Nursing Management
VISUAL DISORDERS
Refractive Errors
Astigmatism
Strabismus
Amblyopia
Nystagmus
Infantile Glaucoma
Congenital Cataract
Retinopathy of Prematurity
Visual Impairment
INFECTIOUS AND INFLAMMATORY DISORDERS OF THE EARS
Acute Otitis Media
Otitis Media With Effusion
Otitis Externa
HEARING LOSS AND DEAFNESS
Nursing Assessment
Nursing Management
KEY CONCEPTS
References
CHAPTER WORKSHEET
CHAPTER 40: Nursing Care of the Child With a Respiratory Disorder
KEY TERMS
Learning Objectives
VARIATIONS IN PEDIATRIC ANATOMY AND PHYSIOLOGY
Nose
Throat
Trachea
Lower Respiratory Structures
Chest Wall
Metabolic Rate and Oxygen Need
COMMON MEDICAL TREATMENTS
NURSING PROCESS OVERVIEW FOR THE CHILD WITH A RESPIRATORY DISORDER
ACUTE INFECTIOUS DISORDERS
Common Cold
Sinusitis
Influenza
Pharyngitis
Tonsillitis
Infectious Mononucleosis
Laryngitis
Croup
Epiglottitis
Bronchiolitis (Respiratory Syncytial Virus)
Pneumonia
Bronchitis
Tuberculosis
ACUTE NONINFECTIOUS DISORDERS
Epistaxis
Foreign Body Aspiration
Acute Respiratory Distress Syndrome
Pneumothorax
CHRONIC RESPIRATORY DISORDERS
Allergic Rhinitis
Asthma
Chronic Lung Disease
Cystic Fibrosis
Apnea
TRACHEOSTOMY
Nursing Assessment
Nursing Management
KEY CONCEPTS
References
CHAPTER WORKSHEET
CHAPTER 41: Nursing Care of the Child With a Cardiovascular Disorder
Key Terms
Learning Objectives
VARIATIONS IN PEDIATRIC ANATOMY AND PHYSIOLOGY
Circulatory Changes From Gestation to Birth
Structural and Functional Differences
COMMON MEDICAL TREATMENTS
NURSING PROCESS OVERVIEW FOR THE CHILD WITH A CARDIOVASCULAR DISORDER
CONGENITAL HEART DISEASE
Pathophysiology
Therapeutic Management
Disorders With Decreased Pulmonary Blood Flow
Disorders With Increased Pulmonary Flow
Obstructive Disorders
Mixed Defects
ACQUIRED CARDIOVASCULAR DISORDERS
Heart Failure
Infective Endocarditis
Acute Rheumatic Fever
Cardiomyopathy
Hypertension
Kawasaki Disease
Hyperlipidemia
HEART TRANSPLANTATION
Surgical Procedure and Postoperative Therapeutic Management
Nursing Management
KEY CONCEPTS
References
CHAPTER WORKSHEET
CHAPTER 42: Nursing Care of the Child With a Gastrointestinal Disorder
KEY TERMS
Learning Objectives
VARIATIONS IN PEDIATRIC ANATOMY AND PHYSIOLOGY
Mouth
Esophagus
Stomach
Intestines
Biliary System
Fluid Balance and Losses
COMMON MEDICAL TREATMENTS
NURSING PROCESS OVERVIEW FOR THE CHILD WITH A GASTROINTESTINAL DISORDER
STRUCTURAL ANOMALIES OF THE GASTROINTESTINAL TRACT
Cleft Lip and Palate
Anorectal Malformations
Meckel Diverticulum
Inguinal and Umbilical Hernias
ACUTE GASTROINTESTINAL DISORDERS
Dehydration
Vomiting
Diarrhea
Oral Candidiasis (Thrush)
Oral Lesions
Hypertrophic Pyloric Stenosis
Intussusception
Malrotation and Volvulus
Appendicitis
CHRONIC GASTROINTESTINAL DISORDERS
Gastroesophageal Reflux
Peptic Ulcer Disease
Constipation and Encopresis
Hirschsprung Disease (Congenital Aganglionic Megacolon)
Short Bowel Syndrome
Inflammatory Bowel Disease
Celiac Disease
Recurrent Abdominal Pain
HEPATOBILIARY DISORDERS
Pancreatitis
Gallbladder Disease
Biliary Atresia
Hepatitis
Cirrhosis and Portal Hypertension
Liver Transplantation
KEY CONCEPTS
References
CHAPTER WORKSHEET
CHAPTER 43: Nursing Care of the Child With a Genitourinary Disorder
KEY TERMS
Learning Objectives
VARIATIONS IN PEDIATRIC ANATOMY AND PHYSIOLOGY
Structural Differences
Urinary Concentration
Urine Output
Reproductive Organ Maturity
COMMON MEDICAL TREATMENTS
NURSING PROCESS OVERVIEW FOR THE CHILD WITH A GENITOURINARY DISORDER
URINARY TRACT AND RENAL DISORDERS
Structural Disorders
Acquired Disorders Resulting in Altered Renal Function
Renal Failure
Dialysis and Transplantation
Renal Transplantation
REPRODUCTIVE ORGAN DISORDERS
Female Disorders
Male Disorders
KEY CONCEPTS
References
CHAPTER WORKSHEET
CHAPTER 44: Nursing Care of the Child With a Neuromuscular Disorder
KEY TERMS
Learning Objectives
VARIATIONS IN PEDIATRIC ANATOMY AND PHYSIOLOGY
Brain and Spinal Cord Development
Myelinization
Muscular Development
COMMON MEDICAL TREATMENTS
NURSING PROCESS OVERVIEW FOR THE CHILD WITH A NEUROMUSCULAR DISORDER
CONGENITAL NEUROMUSCULAR DISORDERS
Neural Tube Defects
ACQUIRED NEUROMUSCULAR DISORDERS
Spinal Cord Injury
Guillain-Barré Syndrome
Myasthenia Gravis
Dermatomyositis
BOTULISM
Nursing Assessment
Nursing Management
KEY CONCEPTS
References
CHAPTER WORKSHEET
CHAPTER 45: Nursing Care of the Child With a Musculoskeletal Disorder
KEY TERMS
Learning Objectives
VARIATIONS IN PEDIATRIC ANATOMY AND PHYSIOLOGY
Myelinization
Muscle Development
Skeletal Development
Growth Plate
Bone Healing
Positional Alterations
COMMON MEDICAL TREATMENTS
Casts
Traction
External Fixation
NURSING PROCESS OVERVIEW FOR THE CHILD WITH A MUSCULOSKELETAL DISORDER
CONGENITAL AND DEVELOPMENTAL DISORDERS
Pectus Excavatum
Limb Deficiencies
Polydactyly/Syndactyly
Metatarsus Adductus
Congenital Clubfoot
Osteogenesis Imperfecta
Developmental Dysplasia of the Hip
Tibia Vara (Blount Disease)
Torticollis
ACQUIRED DISORDERS
Rickets
Slipped Capital Femoral Epiphysis
Legg-Calvé-Perthes Disease
Osteomyelitis
Septic Arthritis
Transient Synovitis of the Hip
Scoliosis
INJURIES
Fracture
Sprains
Overuse Syndromes
Radial Head Subluxation
KEY CONCEPTS
References
CHAPTER WORKSHEET
CHAPTER 46: Nursing Care of the Child With an Integumentary Disorder
KEY TERMS
Learning Objectives
VARIATIONS IN PEDIATRIC ANATOMY AND PHYSIOLOGY
Differences in the Skin Between Children and Adults
Differences in Dark-Skinned Children
Sebaceous and Sweat Glands
COMMON MEDICAL TREATMENTS
NURSING PROCESS OVERVIEW FOR THE CHILD WITH AN INTEGUMENTARY DISORDER
INFECTIOUS DISORDERS
Bacterial Infections
Fungal Infections
INFLAMMATORY SKIN CONDITIONS
Diaper Dermatitis
Atopic Dermatitis
Contact Dermatitis
Erythema Multiforme
Urticaria
Seborrhea
Psoriasis
ACNE
Acne Neonatorum
Acne Vulgaris
INJURIES
Pressure Ulcers
Minor Injuries
Burns
Sunburn
Cold Injury
Human and Animal Bites
Insect Stings and Spider Bites
KEY CONCEPTS
References
CHAPTER WORKSHEET
CHAPTER 47: Nursing Care of the Child With a Hematologic Disorder
KEY TERMS
Learning Objectives
VARIATIONS IN PEDIATRIC ANATOMY AND PHYSIOLOGY
Red Blood Cell Production
Hemoglobin
Iron
COMMON MEDICAL TREATMENTS
NURSING PROCESS OVERVIEW FOR THE CHILD WITH A HEMATOLOGIC DISORDER
ANEMIA
Iron-Deficiency Anemia
Other Nutritional Causes of Anemia
Lead Poisoning
Aplastic Anemia
Hemoglobinopathies
CLOTTING DISORDERS
Idiopathic Thrombocytopenia Purpura
Henoch-Schönlein Purpura
Disseminated Intravascular Coagulation
Hemophilia
Von Willebrand disease
KEY CONCEPTS
References
CHAPTER WORKSHEET
CHAPTER 48: Nursing Care of the Child With an Immunologic Disorder
KEY TERMS
Learning Objectives
VARIATIONS IN PEDIATRIC ANATOMY AND PHYSIOLOGY
Lymph System
Phagocytosis
Cellular Immunity
Humoral Immunity
COMMON MEDICAL TREATMENTS
NURSING PROCESS OVERVIEW FOR THE CHILD WITH AN IMMUNOLOGIC DISORDER
PRIMARY IMMUNODEFICIENCIES
Hypogammaglobulinemia
Wiskott-Aldrich Syndrome
Severe Combined Immune Deficiency
SECONDARY IMMUNODEFICIENCIES
HIV Infection
AUTOIMMUNE DISORDERS
Systemic Lupus Erythematosus
Juvenile Idiopathic Arthritis
ALLERGY AND ANAPHYLAXIS
Food Allergies
Anaphylaxis
Latex Allergy
Key Concepts
References
CHAPTER WORKSHEET
CHAPTER 49: Nursing Care of the Child With an Endocrine Disorder
KEY TERMS
Learning Objectives
VARIATIONS IN ANATOMY AND PHYSIOLOGY
Hormone Production and Secretion
COMMON MEDICAL TREATMENTS
NURSING PROCESS OVERVIEW FOR THE CHILD WITH AN ENDOCRINE DISORDER
PITUITARY DISORDERS
Growth Hormone Deficiency
Hyperpituitarism (Pituitary Gigantism)
Precocious Puberty
Delayed Puberty
Diabetes Insipidus
Syndrome of Inappropriate Antidiuretic Hormone
DISORDERS OF THYROID FUNCTION
Congenital Hypothyroidism
Acquired Hypothyroidism
Hyperthyroidism
DISORDERS RELATED TO PARATHYROID GLAND FUNCTION
DISORDERS RELATED TO ADRENAL GLAND FUNCTION
Congenital Adrenal Hyperplasia
POLYCYSTIC OVARY SYNDROME
DIABETES MELLITUS
KEY CONCEPTS
References
CHAPTER WORKSHEET
CHAPTER 50: Nursing Care of the Child With a Neoplastic Disorder
KEY TERMS
Learning Objectives
CHILDHOOD CANCER VERSUS ADULT CANCER
COMMON MEDICAL TREATMENTS
Chemotherapy
Radiation Therapy
Hematopoietic Stem Cell Transplantation
NURSING PROCESS OVERVIEW FOR THE CHILD WITH A NEOPLASTIC DISORDER
LEUKEMIA
Acute Lymphoblastic Leukemia
Acute Myelogenous Leukemia
LYMPHOMAS
Hodgkin Disease
Non-Hodgkin Lymphoma
BRAIN TUMORS
Pathophysiology
Therapeutic Management
Nursing Assessment
Nursing Management
NEUROBLASTOMA
Nursing Assessment
Nursing Management
BONE AND SOFT TISSUE TUMORS
Osteosarcoma
Ewing Sarcoma
Rhabdomyosarcoma
WILMS TUMOR
Therapeutic Management
Nursing Assessment
Nursing Management
RETINOBLASTOMA
Nursing Assessment
Nursing Management
SCREENING FOR REPRODUCTIVE CANCERS IN ADOLESCENTS
Cervical Cancer
Testicular Cancer
KEY CONCEPTS
References
CHAPTER WORKSHEET
CHAPTER 51: Nursing Care of the Child With a Genetic Disorder
KEY TERMS
Learning Objectives
NURSE’S ROLE AND RESPONSIBILITIES
COMMON MEDICAL TREATMENTS
NURSING PROCESS OVERVIEW FOR THE CHILD WITH A GENETIC DISORDER
COMMON CHROMOSOMAL ABNORMALITIES
Trisomy 21 (Down Syndrome)
Trisomy 18 and Trisomy 13
Turner Syndrome
Klinefelter Syndrome
Fragile X Syndrome
NEUROCUTANEOUS DISORDERS
Neurofibromatosis
OTHER GENETIC DISORDERS
INBORN ERRORS OF METABOLISM
Nursing Assessment
Nursing Management
KEY CONCEPTS
References
CHAPTER WORKSHEET
CHAPTER 52: Nursing Care of the Child With a Cognitive or Mental Health Disorder
KEY TERMS
Learning Objectives
EFFECTS OF MENTAL HEALTH ISSUES ON HEALTH AND DEVELOPMENT
COMMON MEDICAL TREATMENTS
NURSING PROCESS OVERVIEW FOR THE CHILD WITH A MENTAL HEALTH DISORDER
DEVELOPMENTAL AND BEHAVIORAL DISORDERS
Learning Disabilities
Intellectual Disability
Autism Spectrum Disorder
Attention Deficit/ Hyperactivity Disorder
TOURETTE SYNDROME
Nursing Assessment
Nursing Management
EATING DISORDERS
Nursing Assessment
Nursing Management
MOOD DISORDERS
Pathophysiology
Therapeutic Management
Nursing Assessment
ANXIETY DISORDERS
Types of Anxiety Disorders
Pathophysiology
Therapeutic Management
Nursing Assessment
Nursing Management
ABUSE AND VIOLENCE
Child Maltreatment
Münchausen Syndrome by Proxy
Substance Abuse
KEY CONCEPTS
References
CHAPTER WORKSHEET
CHAPTER 53: Nursing Care During a Pediatric Emergency
KEY TERMS
Learning Objectives
COMMON MEDICAL TREATMENTS
NURSING PROCESS OVERVIEW FOR THE CHILD IN AN EMERGENCY SITUATION
NURSING MANAGEMENT OF CHILDREN IN EMERGENCIES
Respiratory Arrest
SHOCK
Pathophysiology
Types of Shock
Nursing Assessment
Nursing Management
CARDIAC ARRHYTHMIAS AND ARREST
Pathophysiology
Nursing Assessment
Nursing Management
NEAR DROWNING
Pathophysiology
Nursing Assessment
Nursing Management
POISONING
Nursing Assessment
Nursing Management
TRAUMA
Nursing Assessment
Nursing Management
KEY CONCEPTS
References
CHAPTER WORKSHEET
Appendix A: Standard Laboratory Values
Appendix B: Clinical Paths
Appendix C: Cervical Dilation Chart
Appendix D: Weight Conversion Charts
Appendix E: Breast-Feeding and Medication Use
GENERAL CONSIDERATIONS
POTENTIAL EFFECTS OF SELECTED MEDICATION CATEGORIES ON THE BREAST-FED INFANT
MEDICATIONS THAT USUALLY ARE CONTRAINDICATED FOR THE BREAST-FEEDING WOMAN
Appendix F: Growth Charts
Appendix G: Denver II Developmental Assessment
Appendix H: Blood Pressure Charts for Children and Adolescents
Appendix I: Down Syndrome Health Care Guidelines
Index

Citation preview

Maternity and Pediatric Nursing SECOND EDITION

Susan Scott Ricci, ARNP, MSN, M.Ed Nursing Faculty University of Central Florida Orlando, Florida Former Nursing Program Director and Faculty Lake Sumter Community College Leesburg, Florida

Terri Kyle, MSN, CPNP Director of Nursing El Camino College Torrance, California

Susan Carman, MSN, MBA Professor of Nursing Most recently, Edison Community College Fort Myers, Florida

Acquisitions Editor: Patrick Barbera Product Manager: Helene T. Caprari, Kristin Royer Editorial Assistant: Jaclyn Clay Design Coordinator: Holly McLaughlin Illustration Coordinator: Brett McNaughton Manufacturing Coordinator: Karin Duffield Prepress Vendor: S4Carlisle Publishing Services 2nd Edition Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins. Copyright © 2009. All rights reserved. This book is protected by copyright. No part of this book may be reproduced or transmitted in any form or by any means, including as photocopies or scanned-in or other electronic copies, or utilized by any information storage and retrieval system without written permission from the copyright owner, except for brief quotations embodied in critical articles and reviews. Materials appearing in this book prepared by individuals as part of their official duties as U.S. government employees are not covered by the above-mentioned copyright. To request permission, please contact Lippincott Williams & Wilkins at Two Commerce Square, 2001 Market Street, Philadelphia, PA 19103, via email at [email protected], or via our website at lww.com (products and services). 9 8 7 6 5 4 3 2 1 Printed in China Library of Congress Cataloging-in-Publication Data Ricci, Susan Scott.   Maternity and pediatric nursing / Susan Scott Ricci, Terri Kyle, Susan Carman.—2nd ed.    p. ; cm.   Includes bibliographical references and index.   ISBN 978-1-60913-747-2 (hardback)—ISBN 1-60913-747-7 (hardback) I. Kyle, Terri.  II. Carman, Susan.  III. Title.  [DNLM: 1. Maternal-Child Nursing. 2. Pediatric Nursing. 3. Women’s Health. WY 157.3]  618.92'00231—dc23 2012021656 Care has been taken to confirm the accuracy of the information presented and to describe generally accepted practices. However, the authors, editors, and publisher are not responsible for errors or omissions or for any consequences from application of the information in this book and make no warranty, expressed or implied, with respect to the currency, completeness, or accuracy of the contents of the publication. Application of this information in a particular situation remains the professional responsibility of the practitioner; the clinical treatments described and recommended may not be considered absolute and universal recommendations. The authors, editors, and publisher have exerted every effort to ensure that drug selection and dosage set forth in this text are in accordance with the current recommendations and practice at the time of publication. However, in view of ongoing research, changes in government regulations, and the constant flow of information relating to drug therapy and drug reactions, the reader is urged to check the package insert for each drug for any change in indications and dosage and for added warnings and precautions. This is particularly important when the recommended agent is a new or infrequently employed drug. Some drugs and medical devices presented in this publication have Food and Drug Administration (FDA) clearance for limited use in restricted research settings. It is the responsibility of the health care provider to ascertain the FDA status of each drug or device planned for use in his or her clinical practice. LWW.com

This book is dedicated to my husband Glenn, whose love is my haven, and through your support makes anything possible. Also to my children, Brian and Jennifer, who have always inspired me throughout their lives. And lastly, to my grandchildren—Leyton, Peyton, Alyssa, Wyatt, Michael and Rylan, who bring me life’s greatest joys. Susan Scott Ricci This text is dedicated to the students who inspire to find new and better ways to convey my passion for the nursing care of families. I also dedicate this edition to my incredible family. Thank you to my husband John who has consistently reminded me of my vision and to my children, Christian and Caitlin, who forever surprise and delight me. Terri Kyle This book is dedicated to all the children out there and the wonderful nurses who care for them. This book is also dedicated to my loving and supportive family. My husband Chris without whom I could not have reached this accomplishment and my three beautiful girls, Grace, Ella and Lily who have allowed me to learn first-hand about growth and development and who truly amaze me each and every day. Susan Carman

Acknowledgments We would like to thank everyone who has helped bring the exciting prospect of this textbook into being, specifically Patrick Barbera, Helene Caprari and Kristin Royer (Product Managers), as well as Holly McLaughlin for her creativity in facilitated the design, and Sarah Kyle for her continued dedication in guiding the vision of the book. S.S.R., T. K. & S.C.

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About the Authors Susan Scott Ricci has a diploma from Washington Hospital Center School of Nursing, with a BSN, MSN, from Catholic University of America in Washington, D.C., and an M.Ed. in Counseling from the University of Southern Mississippi. She has worked in numerous women’s health care settings, including labor and delivery, postpartum, prenatal, and family planning ambulatory care clinics. Susan is a women’s health care nurse practitioner who has spent 301 years in nursing education teaching in LPN, ADN, and BSN programs. She is involved in several professional nursing organizations and holds application of knowledge within nursing practice.

Terri Kyle earned a Bachelor of Science in Nursing from the University of North Carolina at Chapel Hill and a Master of Science in Nursing from Emory University in Atlanta, Georgia. She is a certified pediatric nurse practitioner, and practicing pediatric nursing for over 25 years, she has had the opportunity to serve children and their families in a variety of diverse settings. She has experience in inpatient pediatrics in pediatric and neonatal intensive care units, newborn nursery, specialized ­pediatric units, and community hospitals. She has worked as a ­pediatric nurse practitioner in pediatric specialty clinics and primary care. She has been involved in teaching nursing for over 20  years with experience in both graduate and undergraduate education. Terri is a fellow in the National Association of Pediatric Nurse Practitioners and a member of the Sigma Theta Tau International Honor Society of Nursing, the National League for Nursing, and the Society of Pediatric Nurses. With the limited time allotted in schools to the topic of maternity and pediatric nursing, Terri recognized the need for a textbook that “got to .” She strongly believes in a conceptsbased approach for learning nursing—that is, to teach the basics to students in a broad, contextual format so that they can apply that knowledge in a variety of situations. The concepts-based approach to nursing education is time efficient for nursing educators and fosters the development of critical thinking skills in student nurses. Susan Carman earned a Bachelor of Science in Nursing from the University of Wisconsin-Madison and a Master of Science in Nursing and Master in Business Administration from the University of Colorado-Denver. As a pediatric nurse for over 16  years, Susan has had the opportunity to care for children in a variety of diverse settings and in many of the major children’s hospitals throughout the United States. She also has provided volunteer nursing care in a variety of settings including the Dominican Republic and India. She has been involved in teaching nursing for the past 12 years and enjoys watching students transform into competent nurses with strong critical thinking skills. She is a member of Sigma Theta tau and Beta Gamma Sigma. v

Reviewers to the Second Edition JoAnn Blake, PhD Professor Prairie View A&M University Houston, Texas

Amy Fuller, MSN, RNC Clinical Instructor MGH Institute of Health Professions Boston, Massachusetts

Melissa Gwyn Brandi, RN, MSN Nursing Instructor West Georgia Technical College Carrollton, Georgia

Sue Gabriel, EdD, MSN, MFS, RN Associate Professor BryanLGH College of Health Sciences, School of Nursing Lincoln, Nebraska

Pamela Brandy-Webb, RN, MSN Associate Clinical Professor Prairie View A & M University, College of Nursing Houston, Texas Linda Brice, PhD, RN Assistant Professor Texas Tech University Health Science Lubbock, Texas Susan Brillhart, MSN, RN, PNP-BC Assistant Professor CUNY Borough of Manhattan Community College New York, New York Kim Casper-Bruett, RN, MSN Assistant Professor Mercy College of Health Sciences Des Moines, Iowa Kathleen Cahill, RN, MSN Nursing Instructor Saint Anselm College Manchester, New Hampshire Bonnie Carmack, RN Nursing Instructor Valencia Community College Orlando, Florida Krisann Draves, MSN, ARNP, CPNP-PC Nursing Instructor University of Central Florida Orlando, Florida

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Maeve Howett, PhD, RN Assistant Professor Emory University Decatur, Georgia Sandra Jenkins, PhD, RN, MSN Assistant Professor Prairie View A & M University, College of Nursing Missouri City, Texas Cheryl Johnson, RN, MSN Nursing Instructor Mississippi Gulf Coast Community College Theodore, Alabama Patricia Martin, RN, MSN Assistant Professor West Kentucky Community and Technical College Paducah, Kentucky Katherine Roberts, RN, MSN Nursing Instructor Lamar University Beaumont, Texas Janice Rogers, RN, MSN Nursing Instructor Lee College Baytown, Texas Glenda Smith, PhD, RNC, MSN, PNE Assistant Professor University of Alabama at Birmingham Birmingham, Alabama

Reviewers to the Second Edition    vii

Bonnie Webster, MS, RN, BC Assistant Professor University of Texas Galveston, Texas Barbara Wilford, RN, MSN Assistant Professor Lorain County Community College Elyria, Ohio

Diane Yorke, PhD, RN, CPNP Assistant Professor University of North Carolina Chapel Hill, North Carolina

Preface Many nursing curricula combine and teach maternity and pediatrics in tandem. This can be viewed as a natural fit of two content areas that belong together. Nursing education in general is founded upon the p ­ rinciple of mastering simpler concepts first and incorporating those concepts into the student’s knowledge base. The student is then able to progress to problem solving in more complex situations. In today’s education climate with reduced class time devoted to specialty courses, it is particularly important for nursing educators to focus on key concepts, rather than attempting to cover everything within a specific topic. The intent of Maternity and Pediatric Nursing is to provide the nurse the basis needed for sound nursing care of women and children. The content in the book will enable the reader to guide women and children toward higher levels of wellness throughout the life cycle. In addition, the focus of the textbook will allow the reader to anticipate, identify, and address common problems and provide timely, evidence-based interventions to reduce long-term sequelae. This textbook is designed as a practical approach to understanding the health of women and children. The main objective is to help the student build a strong knowledge base and assist with the development of critical thinking skills. Women in our society are becoming empowered to make informed and responsible choices regarding their health and that of their children, but to do so they need the encouragement and support of nurses who care for them. This textbook focuses on women and children throughout their lifespan, covering a broad scope of topics with emphasis placed upon common issues. Maternity nursing content coverage is comprehensive, yet presented in a concise and straightforward manner. The pediatric nursing content presents the important differences when caring for children compared with caring for adults. A nursing process approach provides relevant information in a concise and non-redundant manner0. The content covered in the text arms the student or practicing nurse with essential information to care for women and their families, to assist them to make the right choices safely, intelligently, and with confidence.

ORGANIZATION Each chapter of Maternity and Pediatric Nursing focuses on a different aspect of maternity and/or pediatric nursing care. The book is divided into eleven units, beginning with general concepts related to maternity and pediatric nursing care, progressing from women’s health, pregnancy and birth, through child health promotion and nursing management of alterations in children’s health.

Unit 1: Introduction to Maternity and Pediatric Nursing Unit  1 helps build a foundation for the student beginning the study of the care of women, infants, and children. This unit explores contemporary issues and trends in maternity and pediatric nursing. Perspectives on women’s health and pediatric nursing, core concepts of maternal and pediatric nursing, including, familycentered and atraumatic care, and communication, and ­community-based nursing are addressed. Unit 2: Women’s Health Throughout the Life span Unit 2 introduces the student to selected women’s health topics, including structure and function of the reproductive system, common reproductive concerns, sexually transmitted infections, problems of the breast, and benign disorders and cancers of the female reproductive tract. This unit encourages the student to assist women in maintaining their quality of life, reducing their risk of disease, and becoming active partners with their health care professional. Unit 3: Pregnancy Unit 3 addresses topics related to normal pregnancy, including fetal development, genetics, and maternal adaptation to pregnancy. Nursing management during normal pregnancy is addressed, encouraging application of basic knowledge to nursing practice. Nursing management includes maternal and fetal assessment throughout pregnancy, interventions to promote self-care and minimize common discomforts, and patient education. Unit 4: Labor and Birth Unit  4 begins with an explanation of the normal labor and birth process, including maternal and fetal adaptations. This is followed by content focusing on the nurse’s

Nursing Process Overview contains NANDA-I approved nursing diagnoses. Material related to nursing diagnoses is from Nursing Diagnoses—Definitions and Classification 2009–2011 © 2009, 2007, 2005, 2003, 2001, 1998, 1996, 1994 NANDA International. Used by arrangement with Wiley-Blackwell Publishing, a company of John Wiley & Sons, Inc. In order to make safe and effective judgments using NANDA-I nursing diagnoses it is essential that nurses refer to the definitions and defining characteristics of the diagnoses listed in this work. 1

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Preface   ix

role during normal labor and birth, which includes maternal and fetal assessment, pharmacologic and nonpharmacologic comfort measures and pain management, and specific nursing interventions during each stage of labor and birth.

Unit 5: Postpartum Period Unit 5 focuses on maternal adaptation during the normal postpartum period. Both physiologic and psychological aspects are explored. Paternal adaptation is also considered. This unit also presents related nursing management, including assessment of physical and emotional status, promoting comfort, assisting with elimination, counseling about sexuality and contraception, promoting nutrition, promoting family adaptation, and preparing for discharge. Unit 6: The Newborn Unit 6 covers physiologic and behavioral adaptations of the normal newborn. It also delves into nursing management of the normal newborn, including immediate assessment and specific interventions as well as ongoing assessment, physical examination, and specific interventions during the early newborn period. Unit 7: Childbearing at Risk Unit 7 shifts the focus to at-risk pregnancy, childbirth, and postpartum care. Pre-existing conditions of the woman, pregnancy-related complications, at-risk labor, emergencies associated with labor and birth, and medical conditions and complications affecting the postpartum woman are all covered. Treatment and nursing management are presented for each medical condition. This organization allows the student to build on a solid foundation of normal material when studying the at-risk content. Unit 8: The Newborn at Risk Unit 8 continues to center on at-risk content. Issues of the newborn with birthweight variations, gestational age variations, congenital conditions, and acquired disorders are explored. Treatment and nursing management are presented for each medical condition. This organization helps cement the student’s understanding of the material. Unit 9: Health Promotion of the Growing Child and Family Unit  9 provides information related to growth and development expectations of the well child from newborn through adolescence. Although not exhaustive in nature, this unit provides a broad knowledge base related to normal growth and development that the nurse can draw on in any situation. Common concerns related to growth and development and client/family education are included in each age-specific chapter. Unit 10: Children and Their Families Unit  10 covers broad concepts that provide the foundation for providing nursing care for children. Rather than

reiterating all aspects of nursing care, the unit focuses on specific details needed to provide nursing care for children in general. The content remains focused upon differences in caring for children compared with adults. Topics covered in this unit include atraumatic care, anticipatory guidance and routine well child care (including immunization and safety), health assessment, nursing care of the child in diverse settings, including the hospital and at home, concerns common to special needs children, pediatric variations in medication and intravenous fluid delivery and nutritional support, and pain management in children.

Unit 11: Nursing Care of the Child With a Health Disorder Unit  11 focuses on children’s responses to health disorders. This unit provides comprehensive coverage of illnesses affecting children and is presented according to broad topics of disorders organized with a body systems approach. It also includes infectious, genetic, and mental health disorders as well as pediatric emergencies. Each chapter follows a similar format in order to facilitate presentation of the information as well as reduce repetition. The chapters begin with a nursing process overview for the particular broad topic, presenting differences in children and how the nursing process applies. The approach provides a general framework for addressing disorders within the chapter. Individual disorders are then addressed with attention to specifics related to pathophysiology, nursing assessment, nursing management, and special considerations. Common pediatric disorders are covered in greater depth than less common disorders. The format of the chapters allows for the building of a strong knowledge base and encourages critical thinking. Additionally, the format is nursing process driven and consistent from chapter to chapter, providing a practical and sensible presentation of the information.

RECURRING FEATURES In order to provide the instructor and student with an exciting and user-friendly text, a number of recurring features have been developed.

Key Terms A list of terms that are considered essential to the chapter’s understanding is presented at the beginning of each chapter. Each key term appears in boldface, with the definition included in the text. Key terms may also be accessed on . Learning Objectives Learning Objectives included at the beginning of each chapter guide the student in understanding what is important and why, leading the student to prioritize information for learning. These valuable learning tools also provide opportunities for self-testing or instructor evaluation of student knowledge and ability.

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Words of Wisdom Each chapter opens with inspiring Words of Wisdom (WOW), which offer helpful, timely, or interesting thoughts. These WOW statements set the stage for each chapter and give the student valuable insight into nursing care of women, children, and their families. Threaded Case Studies Real-life scenarios present relevant woman, child, and family information that is intended to perfect the student’s caregiving skills. Questions about the scenario provide an opportunity for the student to critically evaluate the appropriate course of action. Evidence-Based Practice The consistent promotion of evidence-based practice is a key feature of the text. Throughout the chapters, pivotal questions addressed by current research have been incorporated into Evidence-Based Practice displays, which cite studies relevant to chapter content. Healthy People 2020 Throughout the textbook, relevant Healthy People 2020 objectives are outlined in box format. The nursing implications or guidance provided in the box serve as a roadmap for improving the health of women, mothers, and children. New! Atraumatic Care These highlights, located throughout the pediatric sections of the book, provide tips for providing atraumatic care to children in particular situations in relation to the topic being discussed. New! Thinking About Development The content featured in these boxes in chapters related to the care of children will encourage student to think critically about special developmental concerns relating to the topic being discussed. Teaching Guidelines An important tool for achieving health promotion and disease prevention is health education. Throughout the textbook, Teaching Guidelines raise awareness, provide timely and accurate information, and are designed to ensure the student’s preparation for educating women, children, and their families about various issues. Consider This! In every chapter the student is asked to Consider This! These first-person narratives engage the student in reallife scenarios experienced by their clients. . The personal accounts evoke empathy and help the student to perfect caregiving skills. Each box ends with an opportunity for further contemplation, encouraging the student to think critically about the scenario. Take Note! The Take Note! feature draws the student’s attention to points of critical emphasis throughout the chapter. This

feature is often used to stress life-threatening or otherwise vitally important information.

Drug Guides Drug guide tables summarize information about commonly used medications. The actions, indications, and significant nursing implications presented assist the student in providing optimum care to women, children, and their families. Common Laboratory and Diagnostic Tests The Common Laboratory and Diagnostic Tests tables in many of the chapters provide the student with a general understanding of how a broad range of disorders is diagnosed. Rather than reading the information repeatedly throughout the narrative, the student is then able to refer to the table as needed. Common Medical Treatments The Common Medical Treatments tables in many of the nursing management chapters provide the student with a broad awareness of how a common group of disorders is treated either medically or surgically. The tables serve as a reference point for common medical treatments. Nursing Care Plans Nursing Care Plans provide concrete examples of each step of the nursing process and are included in numerous chapters. The Nursing Care Plans summarize issueor system-related content, thereby minimizing repetition. Comparison Charts These charts compare two or more disorders or other easily confused concepts. They serve to provide an explanation that clarifies the concepts for the student. Nursing Procedures Step-by-step Nursing Procedures are presented in a clear, concise format to facilitate competent performance of relevant procedures as well as to clarify pediatric variations when appropriate. Icons Watch and Learn A special icon throughout the book directs students to free video clips locate on that highlight growth and development, communicating with children, and providing nursing care to the child in the hospital. Concepts in Action Animations These unique animations, also located on bring physiologic and pathophysiologic concepts to life and enhance student comprehension.

Tables, Boxes, Illustrations, and Photographs Abundant tables and boxes summarize key content throughout the book. Additionally, beautiful illustrations and photographs help the student to visualize the content. These features allow the student to quickly and easily access information.

Preface   xi

Key Concepts At the end of each chapter, Key Concepts provide a quick review of essential chapter elements. These bulleted lists help the student focus on the important aspects of the chapter. References and helpful Websites References used in the development of the text are provided at the end of each chapter. These listings enable the student to further explore topics of interest. Many online resources are provided on as a means for the student to electronically explore relevant content material. These resources can be shared with women, children, and their families to enhance patient education and support. Chapter Worksheets Chapter worksheets at the end of each chapter assist the student in reviewing essential concepts. Chapter worksheets include: • Multiple Choice Questions—These review questions are written to test the student’s ability to apply chapter material. Questions cover maternal-newborn and women’s health content that the student might encounter on the national licensing exam (NCLEX). • Critical Thinking Exercises—These exercises challenge the student to incorporate new knowledge with previously learned concepts and reach a satisfactory conclusion. They encourage the student to think critically, problem solve, and consider his or her own perspective on given topics. • Study Activities—These interactive activities promote student participation in the learning process. This section encourages increased interaction/learning via clinical, on-line, and community activities. Teaching–Learning Package Instructor’s Resources Tools to assist you with teaching your course are available upon adoption of this text on at http:// thePoint.lww.com/Ricci-Kyle2e. Many of these tools are also included on the Instructor’s Resource DVD-ROM. • An E-Book on gives you access to the book’s full text and images online. • A Test Generator that features hundreds of questions within a powerful tool to help the instructor create quizzes and tests • PowerPoint presentations with Guided Lecture Notes provide an easy way for you to integrate the textbook with our students’ class-room experience, either via slide shows or handouts. Multiple-choice and true/false questions are integrated into the presentations to promote class participation and allow you to use i-clicker technology. • An Image Bank lets you use the photographs and illustrations from this textbook in your PowerPoint slides or as you see fit in your course.

• New! Case Studies with related questions (and suggested answers) give students an opportunity to apply their knowledge to a client case similar to one they might encounter in practice. • Pre-Lecture Quizzes (and answers) are quick, knowledge-based assessments that allow you to check students’ reading. • Discussion Topics (and suggested answers) can be used as conversation starters or in online discussion boards. • Assignments (and suggested answers) include group, written, clinical, and Web assignments. • Sample Syllabi provide guidance for structuring your pediatric nursing courses and are provided for four different course lengths: 4, 6, 8, and 10 weeks. • Journal Articles, updated for the new edition, offer access to current research available in Lippincott Williams & Wilkins journals. Contact your sales representative or check out LWW.com/Nursing for more details and ordering information. Student Resources An exciting set of free resources is available to help students review material and become even more familiar with vital concepts. Students can access all these resources on at http://thePoint.lww.com/Ricci-Kyle2e using the codes printed in the front of their textbooks. • An E-Book on allows access to the book’s full text and images online. • NCLEX-Style Review Questions for each chapter help students review important concepts and practice for NCLEX. Over 700 questions are included, more than twice as many as last edition! • Multimedia Resources appeal to a variety of learning styles. Icons in the text direct readers to relevant videos and animations: • Watch and Learn Videos A special icon throughout the book directs students to free video clips locate on that highlight growth and development, communicating with children, and providing nursing care to the child in the hospital. • Concepts in Action Animations These unique animations, also located on bring physiologic and pathophysiologic concepts to life and enhance student comprehension. • A Spanish-English Audio Glossary provides helpful terms and phrases for communicating with patients who speak Spanish. • Journal Articles offer access to current research available in Lippincott Williams &Wilkins journals. • And more! ThePoint … where teaching, learning, and technology click! Susan Scott Ricci, Terri Kyle & Susan Carman

Contents UNIT ONE INTRODUCTION TO MATERNITY AND PEDIATRIC NURSING  3 CHAPTER 1 Perspectives

Health Care  5

on Maternal and Child

Historical Development, 6 The History of Maternal and Newborn Health and Health Care, 6 • The History of Child Health and Child Health Care, 6 • Evolution of Maternal and Newborn Nursing, 8 • Evolution of Pediatric Nursing, 9 Health Status of Women and Children, 10 Mortality, 10 • Childhood Mortality, 13 • Morbidity, 13 Factors Affecting Maternal and Child Health, 16 Family, 17 • Genetics, 25 • Society, 27 • Culture, 32 • Health Status and Lifestyle, 36 • Access to Health Care, 40 • Improvements in Diagnosis and Treatments, 41 • Empowerment of Health Care Consumers, 41 Barriers to Health Care, 41 Finances, 41 • Sociocultural Barriers, 41 • Health Care Delivery System Barriers, 42 Legal and Ethical Issues in Maternal and Child Health Care, 42 Abortion, 42 • Substance Abuse, 45 • Intrauterine Therapy, 45 • Maternal–Fetal Conflict, 45 • Stem Cell Research, 45 • Umbilical Cord Blood Banking, 46 • Informed Consent, 46 • Assent, 48 • Refusal of Medical Treatment, 49 • Advance Directives, 50 • Client Rights, 50 • Confidentiality, 51 Implications for Nurses, 51 CHAPTER 2 Core

Concepts of Maternal and Child Health Care and Community-Based Care  58 Core Concepts of Maternal and Child Health Nursing, 59 Family-Centered Care, 59 • Evidence-Based Care, 60 • Collaborative Care, 60 • Atraumatic Pediatric Care, 60 • Communication, 61 • Education, 63 • Discharge Planner and Case Manager, 68 • Client Advocate and Resource Manager, 68 • Preventative Care, 69 • Culturally Competent Nursing Care, 70 • Complementary and Alternative Medicine, 72 Community-Based Care, 74 Community Health Nursing, 74 • Community-Based Nursing, 74 • Shift in Responsibilities From Hospital-Based to Community-Based Nursing, 75 • Community-Based Nursing Interventions, 76 • Community-Based Nursing Challenges, 76 • Community-Based Nursing Care Settings for Women and Children, 77

UNIT TWO WOMEN’S HEALTH THROUGHOUT THE LIFE SPAN  89 CHAPTER 3 Anatomy and Physiology of the Reproductive System  91

Female Reproductive Anatomy and Physiology, 92 External Female Reproductive Organs, 92 • Internal Female Reproductive Organs, 93 • Breasts, 96 • Female Sexual Response, 96 xii

The Female Reproductive Cycle, 97 Menstruation, 97 • Reproductive Cycle, 97 Male Reproductive Anatomy and Physiology, 102 External Male Reproductive Organs, 102 • Internal Male Reproductive Organs, 102 • Male Sexual Response, 104 CHAPTER 4

Common Reproductive Issues  107

Menstrual Disorders, 108 Amenorrhea, 108 • Etiology, 108 • Therapeutic Management, 109 • Nursing Assessment, 109 • Nursing Management, 109 Dysmenorrhea, 110 • Etiology, 110 • Therapeutic Management, 110 • Nursing Assessment, 110 • Nursing Management, 112 Dysfunctional Uterine Bleeding, 113 • Etiology, 113 • Therapeutic Management, 114 • Nursing Assessment, 114 •  Nursing Management, 114 Premenstrual Syndrome, 116 • Therapeutic Management, 116 • Nursing Assessment, 117 • Nursing Management, 117 Endometriosis, 118 • Etiology and Risk Factors, 118 • Therapeutic Management, 119 • Nursing Assessment, 119 • Nursing Management, 120 Infertility, 120 Cultural Considerations, 121 • Etiology and Risk Factors, 122 • Therapeutic Management, 122 • Nursing Assessment, 123 • Nursing Management, 126 Contraception, 126 Types of Contraceptive Methods, 127 • Nursing Management of the Woman Choosing a Contraceptive Method, 144 • Nursing Assessment, 145 • Nursing Diagnoses, 145 • Nursing Interventions, 147 Abortion, 149 Surgical Abortion, 149 • Medical Abortion, 149 Menopausal Transition, 150 Therapeutic Management, 151 • Nursing Assessment, 156 • Nursing Management, 156 CHAPTER 5 Sexually

Transmitted Infections  162

Sexually Transmitted Infections and Adolescents, 163 Nursing Assessment, 164 • Nursing Management, 170 • Infections Characterized by Vaginal Discharge, 170 Genital/Vulvovaginal Candidiasis (VVC), 171 • Therapeutic Management, 172 • Nursing Assessment, 172 • Nursing Management, 173 Trichomoniasis, 173 • Therapeutic Management, 173 • Nursing Assessment, 173 • Nursing Management, 173 Bacterial Vaginosis, 173 • Therapeutic Management, 175 • Nursing Assessment, 175 • Nursing Management, 175 Infections Characterized by Cervicitis, 175 Chlamydia, 175 • Therapeutic Management, 176 • Nursing Assessment, 176 Gonorrhea, 176 • Therapeutic Management, 177 • Nursing Assessment, 177 • Nursing Management of Chlamydia and Gonorrhea, 177 Infections Characterized by Genital Ulcers, 178 Genital Herpes Simplex, 178 • Therapeutic Management, 179 • Nursing Assessment, 179 Syphilis, 179 • Therapeutic Management, 180 • Nursing Assessment, 180 • Nursing Management of Herpes and Syphilis, 181

Contents   xiii

Pelvic Inflammatory Disease, 181 • Therapeutic Management, 182 • Nursing Assessment, 182 • Nursing Management, 183 Vaccine-Preventable STIs, 183 Human Papillomavirus, 183 • Nursing Assessment, 183 • Therapeutic Management, 185 • Nursing Management, 185 Hepatitis A and B, 186 • Therapeutic Management, 186 • Nursing Assessment, 186 • Nursing Management, 186 Hepatitis C, 186

Ectoparasitic Infections, 187 Human Immunodeficiency Virus (HIV), 187 HIV and Adolescents, 188 • Clinical Manifestations, 188 • Diagnosis, 189 • Therapeutic Management, 189 • Nursing Management, 190 Preventing Sexually Transmitted Infections, 192 Behavior Modification, 194 • Contraception, 194

CHAPTER 6

Disorders of the Breasts  198

Benign Breast Disorders, 199

Fibrocystic Breast Changes, 199 • Therapeutic Management, 200 • Nursing Assessment, 200 • Nursing Management, 200 Fibroadenomas, 201 • Therapeutic Management, 202 • Nursing Assessment, 202 • Nursing Management, 204 Mastitis, 204 • Therapeutic Management, 204 • Nursing Assessment, 204 • Nursing Management, 204 Malignant Breast Disorders, 205 Pathophysiology, 205 • Risk Factors, 206 • Diagnosis, 207 • Therapeutic Management, 210 Nursing Process for the Client With Breast Cancer, 215 Breast Cancer Screening, 220 • Nutrition, 221

Benign Disorders of the Female Reproductive Tract  226 CHAPTER 7

Pelvic Support Disorders, 227 Pelvic Organ Prolapse, 227 • Types of Pelvic Organ Prolapse, 227 • Etiology, 228 • Therapeutic Management, 229 • Nursing Assessment, 231 • Nursing Management, 232 Urinary Incontinence, 235 • Pathophysiology and Etiology, 235 • Therapeutic Management, 236 • Nursing Assessment, 237 • Nursing Management, 237 Benign Growths, 238 Polyps, 238 • Therapeutic Management, 238 • Nursing Assessment, 238 • Nursing Management, 239 Uterine Fibroids, 239 • Etiology, 239 • Therapeutic Management, 239 • Nursing Assessment, 240 • Nursing Management, 241 Genital Fistulas, 241 • Therapeutic Management, 241 • Nursing Assessment, 242 • Nursing Management, 242 Bartholin’s Cysts, 242 • Therapeutic Management, 243 • Nursing Assessment, 243 • Nursing Management, 243 Ovarian Cysts, 243 • Types of Ovarian Cysts, 243 • Therapeutic Management, 244 • Nursing Assessment, 245 • Nursing Management, 246

Cancers of the Female Reproductive Tract 250 CHAPTER 8

Nursing Process Overview for the Woman With Cancer of the Reproductive Tract, 251 Ovarian Cancer, 256 Pathophysiology, 257 • Screening and Diagnosis, 258 •

Therapeutic Management, 258 • Nursing Assessment, 258 • Nursing Management, 259 Endometrial Cancer, 260 • Pathophysiology, 260 • Screening and Diagnosis, 262 • Therapeutic Management,  262 • Nursing Assessment, 262 • Nursing Management, 263 Cervical Cancer, 263 • Pathophysiology, 264 • Screening and Diagnosis, 264 • Therapeutic Management, 265 • Nursing Assessment, 266 • Nursing Management, 267 Vaginal Cancer, 271 • Pathophysiology, 271 • Therapeutic Management, 271 • Nursing Assessment, 271 • Nursing Management, 271 Vulvar Cancer, 271 • Pathophysiology, 272 • Screening and Diagnosis, 272 • Therapeutic Management, 272 • Nursing Assessment, 273 • Nursing Management, 273 CHAPTER 9

Violence and Abuse  278

Intimate Partner Violence, 279 Incidence, 280 • Background, 280 • Characteristics of Intimate Partner Violence, 280 • Types of Abuse, 282 • Myths and Facts About Intimate Partner Violence, 282 • Abuse Profiles, 283 • Violence Against Pregnant Women, 284 • Violence Against Older Women, 285 • Nursing Management of Intimate Partner Violence Victims, 285 Sexual Violence, 291 Sexual Abuse, 292 • Incest, 292 • Rape, 293 • Female Genital Cutting, 297 • Human Trafficking, 299 Summary, 300

UNIT THREE PREGNANCY 305 CHAPTER 10 Fetal Development and Genetics  307 Fetal Development, 308 Preembryonic Stage, 308 • Embryonic Stage, 311 • Fetal Stage, 315 • Fetal Circulation, 315 Genetics, 316 Advances in Genetics, 318 • Inheritance, 319 • Patterns of Inheritance for Genetic Disorders, 321 • Chromosomal Abnormalities, 324 Genetic Evaluation and Counseling, 326 Nursing Roles and Responsibilities, 328

Maternal Adaptation During Pregnancy 334 CHAPTER 11

Signs and Symptoms of Pregnancy, 335 Subjective (Presumptive) Signs, 335 • Objective (Probable) Signs, 336 • Positive Signs, 337 Physiologic Adaptations During Pregnancy, 337 Reproductive System Adaptations, 337 • General Body System Adaptations, 339 Changing Nutritional Needs of Pregnancy, 347 Nutritional Requirements During Pregnancy, 350 • Maternal Weight Gain, 353 • Nutrition Promotion, 354 • Special Nutritional Considerations, 354 Psychosocial Adaptations During Pregnancy, 357 Maternal Emotional Responses, 357 • Maternal Role Tasks, 358 • Pregnancy and Sexuality, 358 • Pregnancy and the Partner, 359 •Pregnancy and Siblings, 359

Nursing Management During Pregnancy 363 CHAPTER 12

Preconception Care, 364 Risk Factors for Adverse Pregnancy Outcomes, 364 • Nursing Management, 366

xiv   Contents The First Prenatal Visit, 368 Comprehensive Health History, 369 • Physical Examination, 373 • Laboratory Tests, 376 Follow-Up Visits, 376 Follow-Up Visit Intervals and Assessments, 377 • Fundal Height Measurement, 378 • Fetal Movement Determination, 378 • Fetal Heart Rate Measurement, 379 • Teaching About the Danger Signs of Pregnancy, 379 Assessment of Fetal Well-Being, 380 Ultrasonography, 380 • Doppler Flow Studies, 381 • Alpha-Fetoprotein Analysis, 381 • Marker Screening Tests, 382 • Nuchal Translucency Screening, 382 • Amniocentesis, 383 • Chorionic Villus Sampling, 384 • Percutaneous Umbilical Blood Sampling, 385 • Nonstress Test, 386 • Contraction Stress Test, 386 • Biophysical Profile, 387 Nursing Management for the Common Discomforts of Pregnancy, 388 First-Trimester Discomforts, 388 • Second-Trimester Discomforts, 392 • Third-Trimester Discomforts, 394 Nursing Management to Promote Self-Care, 396 Personal Hygiene, 396 • Clothing, 397 • Exercise, 397 • Sleep and Rest, 398 • Sexual Activity and Sexuality, 399 • Employment, 400 • Travel, 401 • Immunizations and Medications, 402 Nursing Management to Prepare the Woman and Her Partner for Labor, Birth, and Parenthood, 403 Childbirth Education Classes, 403 • Nursing Management and Childbirth Education, 405 • Options for Birth Settings and Care Providers, 405 • Preparation for Breast-Feeding or Bottle-Feeding, 407 • Final Preparation for Labor and Birth, 408

UNIT FOUR LABOR AND BIRTH  415 CHAPTER 13 Labor and Birth Process  417 Initiation of Labor, 418 Premonitory Signs of Labor, 418 Cervical Changes, 418 • Lightening, 418 • Increased Energy Level, 418 • Bloody Show, 418 • Braxton Hicks Contractions, 419 • Spontaneous Rupture of Membranes, 419 True Versus False Labor, 419 Factors Affecting the Labor Process, 420 Passageway, 420 • Passenger, 423 • Powers, 429 • Position (Maternal), 430 • Psychological Response, 431 • Philosophy, 431 • Partners, 431 • Patience, 432 • Patient (Client) Preparation, 433 • Pain Management, 434 Physiologic Responses to Labor, 434 Maternal Responses, 434 • Fetal Responses, 435 Stages of Labor, 435 First Stage, 435 • Second Stage, 437 • Third Stage, 438 • Fourth Stage, 440

Nursing Management During Labor and Birth  444

Nonpharmacologic Measures, 458 • Continuous Labor Support, 458 • Hydrotherapy, 458 • Ambulation and Position Changes, 459 • Acupuncture and Acupressure, 459 • Application of Heat and Cold, 460 • Attention Focusing and Imagery, 462 • Therapeutic Touch and Massage, 462 • Breathing Techniques, 463 • Pharmacologic Measures, 464 • Systemic Analgesia, 464 • Regional Analgesia/Anesthesia, 466 • General Anesthesia, 469 Nursing Care During Labor and Birth, 469 Nursing Care During the First Stage of Labor, 469 • Assessing the Woman Upon Admission, 470 • Continuing Assessment During the First Stage of Labor, 473 • Nursing Interventions, 474 Nursing Management During the Second Stage of Labor, 475 • Assessment, 478 • Nursing Interventions, 479 Nursing Management During the Third Stage of Labor, 482 • Assessment, 482 • Nursing Interventions, 483 Nursing Management During the Fourth Stage of Labor, 483 • Assessment, 483 • Nursing Interventions, 484

UNIT FIVE POSTPARTUM PERIOD  489 CHAPTER 15 Postpartum Adaptations  491 Maternal Physiologic Adaptations, 492 Reproductive System Adaptations, 492 • Cardiovascular System Adaptations, 494 • Urinary System Adaptations, 496 • Gastrointestinal System Adaptations, 496 • Musculoskeletal System Adaptations, 497 • Integumentary System Adaptations, 497 • Respiratory System Adaptations, 497 • Endocrine System Adaptations, 497 Cultural Considerations for the Postpartum Period, 501 Psychological Adaptations, 501 Parental Attachment Behaviors, 501 • Maternal Psychological Adaptations, 502 • Partner Psychological Adaptations, 504

Nursing Management During the Postpartum Period  508 CHAPTER 16

Social Support and Cultural Considerations, 509 Nursing Assessment, 510 Vital Signs Assessment, 511 • Physical Assessment, 512 • Psychosocial Assessment, 515 Nursing Interventions, 518 Providing Optimal Cultural Care, 520 • Promoting Comfort, 520 • Assisting With Elimination, 523 • Promoting Activity, Rest, and Exercise, 524 • Preventing Stress Incontinence, 525 • Assisting With Self-Care Measures, 526 • Ensuring Safety, 526 • Counseling About Sexuality and Contraception, 527 • Promoting Maternal Nutrition, 527 • Supporting the Woman’s Choice of Infant Feeding Method, 528 • Teaching About Breast Care, 531 • Promoting Family Adjustment and Well-Being, 532 • Preparing for Discharge, 536

CHAPTER 14

Maternal Assessment During Labor and Birth, 445 Vaginal Examination, 445 • Assessing Uterine Contractions, 447 • Performing Leopold’s Maneuvers, 447 Fetal Assessment During Labor and Birth, 447 Analysis of Amniotic Fluid, 447 • Analysis of the FHR, 449 • Other Fetal Assessment Methods, 456 • Promoting Comfort and Providing Pain Management During Labor, 457

UNIT SIX THE NEWBORN  547 CHAPTER 17 Newborn Transitioning  549 Physiologic Transitioning, 550 Cardiovascular System Adaptations, 550 • Respiratory System Adaptations, 553 • Body Temperature Regulation, 554 • Hepatic System Function, 558 • Gastrointestinal System Adaptations, 559 • Renal System Changes, 560 •

Contents   xv Immune System Adaptations, 561 • Integumentary System Adaptations, 562 • Neurologic System Adaptations, 562 Behavioral Adaptations, 563 Behavioral Patterns, 563 • Newborn Behavioral Responses, 564

Nursing Management of the Newborn  567 CHAPTER 18

Nursing Management During the Immediate Newborn Period, 568 Assessment, 569 • Nursing Interventions, 573 Nursing Management During the Early Newborn Period, 576 Assessment, 577 • Nursing Interventions, 592

UNIT SEVEN CHILDBEARING AT RISK  623 CHAPTER 19 Nursing Management of Pregnancy at Risk: Pregnancy-Related Complications 625 Bleeding During Pregnancy, 626 Spontaneous Abortion, 627 • Pathophysiology, 628 • Nursing Assessment, 628 • Nursing Management, 628 Ectopic Pregnancy, 631 • Pathophysiology, 631 • Therapeutic Management, 631 • Nursing Assessment, 632 • Nursing Management, 633 Gestational Trophoblastic Disease, 634 • Pathophysiology, 634 • Therapeutic Management, 634 • Nursing Assessment, 635 • Nursing Management, 635 Cervical Insufficiency, 636 • Pathophysiology, 636 • Therapeutic Management, 636 • Nursing Assessment, 637 • Nursing Management, 638 Placenta Previa, 638 • Pathophysiology, 638 • Therapeutic Management, 639 • Nursing Assessment, 639 • Nursing Management, 639 Abruptio Placentae, 642 • Pathophysiology, 642 • Therapeutic Management, 642 • Nursing Assessment, 643 • Nursing Management, 645

Placenta Accreta, 646

Hyperemesis Gravidarum, 646 Pathophysiology, 646 • Therapeutic Management, 646 • Nursing Assessment, 647 • Nursing Management, 648 Hypertensive Disorders of Pregnancy, 649

Chronic Hypertension, 649 Gestational Hypertension, 650 Preeclampsia and Eclampsia, 650 • Pathophysiology, 650 •

Therapeutic Management, 651 • Nursing Assessment, 652 • Nursing Management, 653 HELLP Syndrome, 658 Pathophysiology, 658 • Therapeutic Management, 658 • Nursing Assessment, 658 • Nursing Management, 659 Gestational Diabetes, 659 Blood Incompatibility, 659 Pathophysiology, 659 • Nursing Assessment, 660 • Nursing Management, 660 Amniotic Fluid Imbalances, 660 Hydramnios, 660 • Therapeutic Management, 660 • Nursing Assessment, 661 • Nursing Management, 661 Oligohydramnios, 661 • Therapeutic Management, 661 • Nursing Assessment, 661 • Nursing Management, 662 Multiple Gestation, 662 Therapeutic Management, 662 • Nursing Assessment, 663 • Nursing Management, 663 Premature Rupture of Membranes, 663

Therapeutic Management, 663 • Nursing Assessment, 664 • Nursing Management, 665

Nursing Management of the Pregnancy at Risk: Selected Health Conditions and Vulnerable Populations  670 CHAPTER 20

Diabetes Mellitus, 671 Pathophysiology, 672 • Screening, 672 • Therapeutic Management, 674 • Nursing Assessment, 676 • Nursing Management, 678 Cardiovascular Disorders, 682 Congenital and Acquired Heart Disease, 682 • Pathophysiology, 685 • Therapeutic Management, 686 • Nursing Assessment, 686 • Nursing Management, 687 Chronic Hypertension, 688 • Therapeutic Management, 688 • Nursing Assessment, 688 • Nursing Management, 688 Respiratory Conditions, 689 Asthma, 689 • Pathophysiology, 689 • Therapeutic Management, 690 • Nursing Assessment, 690 • Nursing Management, 691 Tuberculosis, 692 • Therapeutic Management, 692 • Nursing Assessment, 692 • Nursing Management, 693 Hematologic Conditions, 693 Iron-Deficiency Anemia, 693 • Therapeutic Management, 693 • Nursing Assessment, 693 • Nursing Management, 694

Thalassemia, 694 Sickle Cell Anemia, 695 • Pathophysiology, 695 •

Therapeutic Management, 695 • Nursing Assessment, 695 • Nursing Management, 695 Autoimmune Disorders, 696 Systemic Lupus Erythematosus, 696 • Pathophysiology, 696 • Therapeutic Management, 696 • Nursing Assessment, 697 • Nursing Management, 697

Multiple Sclerosis, 697 Rheumatoid Arthritis, 698

Infections, 698

Cytomegalovirus, 698 Rubella, 700 Herpes Simplex Virus, 701 Hepatitis B Virus, 701 • Nursing Assessment, 702 • Nursing Management, 702

Varicella Zoster Virus, 702 Parvovirus B19, 703 • Pathophysiology, 703 • Therapeutic

Management, 703 • Nursing Assessment, 703 • Nursing Management, 704 Group B Streptococcus, 704 • Therapeutic Management, 704 • Nursing Assessment, 704 • Nursing Management, 704

Toxoplasmosis, 704 Women Who Are HIV Positive, 705 • Pathophysiology,

705 • Impact of HIV on Pregnancy, 706 • Therapeutic Management, 707 • Nursing Assessment, 707 • Nursing Management, 708 Vulnerable Populations, 709 Pregnant Adolescent, 709 • Impact of Pregnancy in Adolescence, 710 • Developmental Issues, 711 • Health and Social Issues, 712 • Nursing Assessment, 712 • Nursing Management, 712 The Pregnant Woman Over Age 35, 714 • Impact of Pregnancy on the Older Woman, 714 • Nursing Assessment, 714 • Nursing Management, 714

The Obese Pregnant Woman, 714 The Pregnant Woman with Substance Abuse, 715 •

Impact of Substance Abuse on Pregnancy, 715 • Nursing Assessment, 720 • Nursing Management, 721

xvi   Contents

Nursing Management of Labor and Birth at Risk  728 CHAPTER 21

Dystocia, 729

Problems Problems Problems Problems

with with with with

the the the the

Powers, 729 Passenger, 737 Passageway, 739 Psyche, 739 • Nursing Assessment, 739

Nursing Management, 739 Preterm Labor, 741 Therapeutic Management, 741 • Nursing Assessment, 743 • Nursing Management, 745 Prolonged Pregnancy, 747 Nursing Assessment, 748 • Nursing Management, 748 Women Requiring Labor Induction and Augmentation, 749 Therapeutic Management, 749 • Nursing Assessment, 752 • Nursing Management, 753 Vaginal Birth After Cesarean, 755 Intrauterine Fetal Demise, 756 Nursing Assessment, 757 • Nursing Management, 757 Women Experiencing an Obstetric Emergency, 757 Umbilical Cord Prolapse, 758 • Pathophysiology, 758 • Nursing Assessment, 758 • Nursing Management, 758

Placenta Previa, 758 Placental Abruption, 759 Uterine Rupture, 759 • Nursing Assessment, 760 • Nursing Management, 760

Amniotic Fluid Embolism, 760 • Pathophysiology, 760 •

Nursing Assessment, 760 • Nursing Management, 761 Women Requiring Birth-Related Procedures, 761

Amnioinfusion, 761 Forceps- or Vacuum-Assisted Birth, 762 Cesarean Birth, 762 • Nursing Assessment, 763 • Nursing

Management, 764

Nursing Management of the Postpartum Woman at Risk  768 CHAPTER 22

Postpartum Hemorrhage, 769 Pathophysiology, 769 • Therapeutic Management, 772 Nursing Assessment, 772 • Nursing Management, 774 Thromboembolic Conditions, 778 Pathophysiology, 778 • Nursing Assessment, 778 • Nursing Management, 779 Postpartum Infection, 780

Metritis, 781 Wound Infections, 781 Urinary Tract Infections, 781 Mastitis, 781 • Therapeutic Management, 782 • Nursing

Assessment, 782 • Nursing Management, 785 Postpartum Affective Disorders, 787

Postpartum or Baby Blues, 788 Postpartum Depression, 788 Postpartum Psychosis, 790 • Nursing Assessment, 790 •

Nursing Management, 792

UNIT EIGHT THE NEWBORN AT RISK  799 CHAPTER 23 Nursing Care of the Newborn With Special Needs 801 Birthweight Variations, 802

Small-For-Gestational-Age Newborns, 803 • Nursing Assessment, 803 • Nursing Management, 804

Large-For-Gestational-Age Newborns, 808 • Nursing

Assessment, 808 • Nursing Management, 808

Gestational Age Variations, 809 Postterm Newborn, 809 • Nursing Assessment, 809 • Nursing Management, 809 Preterm Newborn, 810 • Effects of Prematurity on Body Systems, 811 • Nursing Assessment, 812 • Nursing Management, 813 • Preparing for Discharge, 824 • Dealing With Perinatal Loss, 825

Late Preterm Newborn (“Near Term”), 827

CHAPTER 24 Nursing Management of the Newborn at Risk: Acquired and Congenital Newborn Conditions 833

Acquired Disorders, 834

Perinatal Asphyxia, 834 • Pathophysiology, 835 • Nursing Assessment, 835 • Nursing Management, 835 Transient Tachypnea of the Newborn, 837 • Pathophysiology, 837 • Nursing Assessment, 837 • Nursing Management, 837 Respiratory Distress Syndrome, 837 • Pathophysiology, 838 • Nursing Assessment, 838 • Nursing Management, 839 Meconium Aspiration Syndrome, 841 • Pathophysiology, 841 • Nursing Assessment, 841 • Nursing Management, 842 Persistent Pulmonary Hypertension of the Newborn, 842 • Pathophysiology, 843 • Nursing Assessment, 843 • Nursing Management, 843

Intraventricular Hemorrhage, 843

Pathophysiology, 843 • Nursing Assessment, 844 • Nursing Management, 844 Necrotizing Enterocolitis, 844 • Pathophysiology, 844 • Nursing Assessment, 845 • Nursing Management, 845 Infants of Diabetic Mothers, 846 • Impact of Diabetes on the Newborn, 846 • Pathophysiology, 847 • Nursing Assessment, 848 • Nursing Management, 849 Birth Trauma, 851 • Pathophysiology, 852 • Nursing Assessment, 853 • Nursing Management, 854 Newborns of Substance-Abusing Mothers, 854 • Fetal Alcohol Spectrum Disorders (FASDs), 857 • Neonatal Abstinence Syndrome, 858 • Nursing Assessment, 859 • Nursing Management, 859 Hyperbilirubinemia, 863 • Pathophysiology, 863 • Nursing Assessment, 865 • Nursing Management, 866 • Newborn Infections, 868 • Pathophysiology, 868 • Nursing Assessment, 870 • Nursing Management, 870 Congenital Conditions, 872

Esophageal Atresia and Tracheoesophageal Fistula, 872 • Pathophysiology, 872 • Nursing Assessment, 872 • Nursing Management, 872

Omphalocele and Gastroschisis, 874 • Nursing

Assessment, 874 • Nursing Management, 874 Anorectal Malformations, 875 • Nursing Assessment, 875 • Nursing Management, 876 Bladder Exstrophy, 876 • Nursing Assessment, 876 • Nursing Management, 877

UNIT NINE

HEALTH PROMOTION OF THE GROWING CHILD AND FAMILY 883 CHAPTER 25 Growth

and Infant  885

and Development of the Newborn

Growth and Development Overview, 886 Physical Growth, 886 • Weight, 886 • Height, 886 • Head and Chest Circumference, 887

Contents   xvii

Organ System Maturation, 887 • Neurologic System, 887 • Respiratory System, 892 • Cardiovascular System, 892 • Gastrointestinal System, 893 • Genitourinary System, 894 • Integumentary System, 894 • Hematopoietic System, 894 • Immunologic System, 895

Fine Motor Skills, 955

Fine Motor Skills, 896

957 • Temperament, 957 • Fears, 958

Psychosocial Development, 895 Cognitive Development, 895 Motor Skill Development, 895 • Gross Motor Skills, 895 • Sensory Development, 897 • Sight, 897 • Hearing, 897 •

Smell and Taste, 898 • Touch, 898

Communication and Language Development, 898 Social and Emotional Development, 901 • Stranger

Anxiety, 902 • Separation Anxiety, 902 • Temperament, 902

Cultural Influences on Growth and Development, 902

The Nurse’s Role in Newborn and Infant Growth and Development, 903 Nursing Process Overview, 903

Promoting Healthy Growth and Development, 903 •

Promoting Growth and Development Through Play, 907 • Promoting Early Learning, 907 • Promoting Safety, 907 • Safety in the Car, 907 • Safety in the Home, 908 • Safety in the Water, 909 • Promoting Nutrition, 909 • Promoting Healthy Sleep and Rest, 913 • Promoting Healthy Teeth and Gums, 914 • Promoting Appropriate Discipline, 914 • Addressing Child Care Needs, 915

Addressing Common Developmental Concerns, 915 •

Colic, 915 • Spitting Up, 915 • Thumb Sucking, Pacifiers, and Security Items, 916 • Teething, 916 CHAPTER 26 Growth and Development of the Toddler 

920

Physical Growth, 921 Organ System Maturation, 921 • Neurologic

System, 921 • Respiratory System, 921 • Cardiovascular System, 922 • Gastrointestinal System, 922 • Genitourinary System, 922 • Musculoskeletal System, 922 Psychosocial Development, 922 • Cognitive Development, 922 Motor Skill Development, 923 • Gross Motor Skills, 923 • Fine Motor Skills, 924

Sensory Development, 925 Communication and Language Development, 925 Emotional and Social Development, 927 • Separation Anxiety, 928 • Temperament, 928 • Fears, 928

Moral and Spiritual Development, 928 Cultural Influences on Growth and Development, 928

The Nurse’s Role in Toddler Growth and Development, 929 Nursing Process Overview, 929 Promoting Healthy Growth and Development, 929 • Promoting Growth and Development Through Play, 933 • Promoting Early Learning, 934 • Promoting Safety, 935 • Promoting Nutrition, 938 • Promoting Healthy Sleep and Rest, 941 • Promoting Healthy Teeth and Gums, 941 • Promoting Appropriate Discipline, 943 Addressing Common Developmental Concerns, 944 • Toilet Teaching, 944 • Negativism, 945 • Temper Tantrums, 946 • Thumb Sucking and Pacifiers, 946 • Sibling Rivalry, 946 • Regression, 947

and Development of the Preschooler  950 Growth and Development Overview, 951

Physical Growth, 951 Organ System Maturation, 951

Sensory Development, 955 Communication and Language Development, 955 Emotional and Social Development, 956 • Friendships, Cultural Influences on Growth and Development, 958

The Nurse’s Role in Preschool Growth and Development, 958 Nursing Process Overview, 959

Promoting Healthy Growth and Development, 959 • Promoting Growth and Development Through

Play, 963 • Promoting Early Learning, 964 • Promoting Language Development, 964 • Choosing a Preschool/Starting Kindergarten, 965 • Promoting Safety, 965 • Safety in the Water, 967 • Promoting Nutrition, 968 • Promoting Healthy Sleep and Rest, 970 • Promoting Healthy Teeth and Gums, 970 • Promoting Appropriate Discipline, 971 Addressing Common Developmental Concerns, 972 • Lying, 972 • Sex Education, 972 • Masturbation, 973 CHAPTER 28 Growth

and Development of the School-Age Child  976 Growth and Development Overview, 977

Physical Growth, 977 Organ Systems Maturation, 977 • Neurologic System,

Growth and Development Overview, 921

CHAPTER 27 Growth

Psychosocial Development, 951 Cognitive Development, 952 Moral and Spiritual Development, 952 Motor Skill Development, 954 • Gross Motor Skills, 954 •

978 • Respiratory System, 978 • Cardiovascular System, 978 • Gastrointestinal System, 978 • Genitourinary System, 978 • Prepubescence, 978 • Musculoskeletal System, 978 • Immune System, 978

Psychosocial Development, 978 Cognitive Development, 979 Moral and Spiritual Development, 980 Motor Skill Development, 980 • Gross Motor Skills, 980 • Fine Motor Skills, 981

Sensory Development, 981 Communication and Language Development, 981 Emotional and Social Development, 982 •

Temperament, 982 • Self-Esteem Development, 982 • Body Image, 982 • School-Age Fears, 982 • Peer Relationships, 983 • Teacher and School Influences, 983 • Family Influences, 983

Cultural Influences on Growth and Development, 983

The Nurse’s Role in School-Age Growth and Development, 984 Nursing Process Overview, 984

Promoting Healthy Growth and Development, 984 •

Promoting Growth and Development Through Play, 984 • Promoting Learning, 987 • Promoting Safety, 987 • Abuse in Children, 990 • Promoting Nutrition, 991 • Promoting Healthy Sleep and Rest, 994 • Promoting Healthy Teeth and Gums, 994 • Promoting Appropriate Discipline, 995

Addressing Common Developmental Concerns, 996 • Television and Video Games, 997 • School Phobia, 997 • Latchkey Children, 998 • Stealing, Lying, and Cheating, 998 • Bullying, 999 • Tobacco and Alcohol Education, 999 CHAPTER 29 Growth

and Development of the Adolescent  1003 Growth and Development Overview, 1004

Physiologic Changes Associated with Puberty, 1004 Physical Growth, 1005 Organ System Maturation, 1006 • Neurologic System,

xviii   Contents 1006 • Respiratory System, 1006 • Cardiovascular System, 1006 • Gastrointestinal System, 1006 • Musculoskeletal System, 1006 • Integumentary System, 1006

Psychosocial Development, 1006 Cognitive Development, 1007 Moral and Spiritual Development, 1007 Motor Skill Development, 1007 • Gross Motor Skills,

1007 • Fine Motor Skills, 1009

Communication and Language Development, 1009 Emotional and Social Development, 1009 • Relationship With Parents, 1009 • Self-Concept and Body Image, 1010 • Importance of Peers, 1010 • Sexuality and Dating, 1010

Cultural Influences on Growth and Development, 1011

The Nurse’s Role in Adolescent Growth and Development, 1012 Nursing Process Overview, 1012

Promoting Healthy Growth and Development, 1012 •

Promoting Growth and Development Through Sports and Physical Fitness, 1015 • Promoting Learning, 1016 • School, 1016 • Other Activities, 1016 • Promoting Safety, 1016 • Promoting Nutrition, 1019 • Promoting Healthy Sleep and Rest, 1022 • Promoting Healthy Teeth and Gums, 1022 • Promoting Personal Care, 1022 • Promoting Appropriate Discipline, 1024 Addressing Common Developmental Concerns, 1024 • Violence, 1024 • Substance Use, 1026

UNIT TEN

CHILDREN AND THEIR FAMILIES  1035 CHAPTER 30 Atraumatic

and Families  1037

Care of Children

Preventing/Minimizing Physical Stressors, 1038 Utilizing the Child Life Specialist, 1038 • Minimizing Physical Stress During Procedures, 1039 Preventing or Minimizing Child and Family Separation: Providing Client- and Family-Centered Care, 1042 Promoting a Sense of Control, 1043 Enhancing Communication, 1043 • Teaching Children and Families, 1045 CHAPTER 31 Health

Supervision  1051

Principles of Health Supervision, 1052 Wellness, 1052 • Medical Home, 1052 • Partnerships, 1052 • Special Issues in Health Supervision, 1053 Components of Health Supervision, 1054 Developmental Surveillance and Screening, 1055 • Injury and Disease Prevention, 1057 • Health Promotion, 1077 CHAPTER 32 Health

Assessment of Children  1085

Health History, 1086 Preparing for the Health History, 1086 • Performing a Health History, 1088 Physical Examination, 1091 Preparing for the Physical Examination, 1091 • Steps of the Physical Examination, 1095 • Performing a Physical Examination, 1095 CHAPTER 33 Caring for Children in Diverse Settings 

1126

Hospitalization in Childhood, 1127 Children’s Reactions to Hospitalization, 1127 • Factors Affecting Children’s Reaction to Hospitalization, 1128 • Family’s Reactions to the Child’s Hospitalization, 1131 • The Nurse’s Role in Caring for the Hospitalized Child, 1133 Community Care in Childhood, 1152 Community-Based Nursing Settings, 1153

CHAPTER 34 Caring

for the Special Needs Child  1163

The Medically Fragile Child, 1164 Impact of the Problem, 1164 • Effects of Special Needs on the Child, 1164 • Effects on the Family, 1165 • Nursing Management of the Medically Fragile Child and Family, 1166 The Dying Child, 1177 End-of-Life Decision Making, 1177 • Nursing Management of the Dying Child, 1178 CHAPTER 35

Key Pediatric Nursing Interventions  1184

Medication Administration, 1185 Differences in Pharmacodynamics and Pharmacokinetics, 1185 • Developmental Issues and Concerns, 1186 • Determination of Correct Dose, 1186 • Oral Administration, 1187 • Rectal Administration, 1189 • Ophthalmic Administration, 1190 • Otic Administration, 1191 • Nasal Administration, 1191 • Intramuscular Administration, 1192 • Subcutaneous and Intradermal Administration, 1192 • Intravenous Administration, 1194 • Providing Atraumatic Care, 1194 • Educating the Child and Parents, 1195 • Preventing Medication Errors, 1197 Intravenous Therapy, 1197 Sites, 1197 • Equipment, 1198 • Inserting Peripheral IV Access Devices, 1199 • IV Fluid Administration, 1200 • Preventing Complications, 1201 • Discontinuing the IV Device, 1202 Providing Nutritional Support, 1203 Enteral Nutrition, 1203 • Parenteral Nutrition, 1210 CHAPTER 36 Pain

Management in Children  1215

Physiology of Pain, 1216 Transduction, 1216 • Transmission, 1216 • Perception, 1217 • Modulation, 1217 Types of Pain, 1217 Classification by Duration, 1218 • Classification by Etiology, 1218 • Classification by Source or Location, 1218 Factors Influencing Pain, 1219 Age and Gender, 1219 • Cognitive Level, 1219 • Temperament, 1219 • Previous Pain Experiences, 1219 • Family and Culture, 1219 • Situational Factors, 1220 Developmental Considerations, 1220 Infants, 1220 • Toddlers, 1221 • Preschoolers, 1221 • SchoolAge Children, 1221 • Adolescents, 1221 Common Fallacies and Myths about Pain in Children, 1221 Nursing Process Overview for the Child in Pain, 1222 Management of Pain, 1235 Nonpharmacologic Management, 1235 • Pharmacologic Management, 1238 • Management of Procedure-Related Pain, 1246 • Management of Chronic Pain, 1247

UNIT ELEVEN

NURSING CARE OF THE CHILD WITH A HEALTH DISORDER  1255 CHAPTER 37 Nursing

Care of the Child With an Infectious or Communicable Disorder  1257 Infectious Process, 1258 Fever, 1259 • Stages of Infectious Disease, 1260 • Chain of Infection, 1260 • Preventing the Spread of Infection, 1260 Variations in Pediatric Anatomy and Physiology, 1261 Common Medical Treatments, 1263 Nursing Process Overview for the Child With an Infectious or Communicable Disorder, 1263 Sepsis, 1274 Pathophysiology, 1274 • Therapeutic Management, 1274 • Nursing Assessment, 1275 • Nursing Management, 1276

Contents   xix Bacterial Infections, 1276

Community-Acquired Methicillin-Resistant

Staphylococcus Aureus, 1276 • Nursing Assessment, 1276 • Nursing Management, 1277

Scarlet Fever, 1277 • Nursing Assessment, 1277 • Nursing Management, 1277

Diphtheria, 1277 • Nursing Assessment, 1278 • Nursing Management, 1278

Pertussis, 1278 • Therapeutic Management, 1279 •

Nursing Assessment, 1279 • Nursing Management, 1279 Tetanus, 1279 • Therapeutic Management, 1280 • Nursing Assessment, 1280 • Nursing Management, 1280 Viral Infections, 1280 Viral Exanthems, 1280 • Nursing Assessment, 1280 • Nursing Management, 1286 Mumps, 1286 • Nursing Assessment, 1286 • Nursing Management, 1286 Zoonotic Infections, 1287 Cat Scratch Disease, 1287• Nursing Assessment, 1287 • Nursing Management, 1287 Rabies, 1287 • Nursing Assessment, 1290 • Nursing Management, 1290 Vector-Borne Infections, 1291 Lyme Disease, 1291• Therapeutic Management, 1291 • Nursing Assessment, 1291 • Nursing Management, 1292 Rocky Mountain Spotted Fever, 1292 • Therapeutic Management, 1292 • Nursing Assessment, 1293 • Nursing Management, 1293 Parasitic and Helminthic Infections, 1293 Nursing Assessment and Management, 1293 Sexually Transmitted Infections, 1298 CHAPTER 38 Nursing

Care of the Child With a Neurologic Disorder  1302 Variations in Pediatric Anatomy and Physiology, 1303 Brain and Spinal Cord Development, 1303 • Nervous System, 1303 • Head Size, 1303 Common Medical Treatments, 1303 Nursing Process Overview for the Child With a Neurologic Disorder, 1303 Seizure Disorders, 1314 Epilepsy, 1314 • Pathophysiology, 1314 • Therapeutic Management, 1322 • Nursing Assessment, 1322 • Nursing Management, 1324 Febrile Seizures, 1325 • Therapeutic Management, 1326 • Nursing Assessment, 1326 • Nursing Management, 1326 Neonatal Seizures, 1326 • Therapeutic Management, 1326 • Nursing Assessment, 1326 • Nursing Management, 1327 Structural Defects, 1327 Neural Tube Defects, 1327 • Anencephaly, 1327 • Nursing Assessment, 1328 • Nursing Management, 1328 • Encephalocele, 1328 • Nursing Assessment, 1328 • Nursing Management, 1328 Microcephaly, 1328 • Nursing Assessment, 1329 • Nursing Management, 1329 Arnold-Chiari Malformation, 1329 • Nursing Assessment, 1329 • Nursing Management, 1329 • Hydrocephalus, 1329 • Pathophysiology, 1330 • Therapeutic Management, 1330 • Nursing Assessment, 1330 • Nursing Management, 1332 Intracranial Arteriovenous Malformation, 1333 • Therapeutic Management, 1333• Nursing Assessment, 1333 • Nursing Management, 1333 Craniosynostosis, 1333 • Nursing Assessment, 1333 • Nursing Management, 1335 Positional Plagiocephaly, 1335 • Nursing Assessment, 1335 • Nursing Management, 1335 Infectious Disorders, 1336

Bacterial Meningitis, 1336 • Pathophysiology, 1336 •

Therapeutic Management, 1336 • Nursing Assessment, 1336 • Nursing Management, 1337 Aseptic Meningitis, 1339 • Therapeutic Management, 1339 • Nursing Assessment, 1339 • Nursing Management, 1339 Encephalitis, 1339 • Nursing Assessment, 1339 • Nursing Management, 1340 Reye Syndrome, 1340 • Nursing Assessment, 1340 • Nursing Management, 1341 Trauma, 1341 Head Trauma, 1341 • Nursing Assessment, 1341 • Nursing Management, 1343 Nonaccidental Head Trauma, 1344 • Nursing Assessment, 1345 • Nursing Management, 1345 Near Drowning, 1347 • Nursing Assessment, 1347 • Nursing Management, 1347 Blood Flow Disruption, 1347 Cerebral Vascular Disorders (Stroke), 1347 • Nursing Assessment, 1348 • Nursing Management, 1348 Chronic Disorders, 1348 Headaches, 1348 • Nursing Assessment, 1349 • Nursing Management, 1349 Breath Holding, 1349 • Nursing Assessment, 1350 • Nursing Management, 1350 CHAPTER 39 Nursing

Care of the Child With a Disorder of the Eyes or Ears  1354 Variations in Pediatric Anatomy and Physiology, 1355 Eyes, 1355 • Ears, 1355 Common Medical Treatments, 1355 Nursing Process Overview for the Child With a Disorder of the Eyes or Ears, 1356 Infectious and Inflammatory Disorders of the Eyes, 1359 Conjunctivitis, 1359 • Pathophysiology, 1359 • Therapeutic Management, 1363 • Nursing Assessment, 1363 • Nursing Management, 1364 Nasolacrimal Duct Obstruction, 1365 • Nursing Assessment, 1365 • Nursing Management, 1365 Eyelid Disorders, 1365 • Nursing Assessment, 1365 • Nursing Management, 1366 Periorbital Cellulitis, 1366 • Nursing Assessment, 1366 • Nursing Management, 1367 Eye Injuries, 1367 Nursing Assessment, 1367 • Nursing Management, 1368 Visual Disorders, 1370 Refractive Errors, 1370 • Nursing Assessment, 1370 • Nursing Management, 1371 Astigmatism, 1371 • Nursing Assessment, 1371 • Nursing Management, 1371 Strabismus, 1372 • Nursing Assessment, 1372 • Nursing Management, 1372 Amblyopia, 1372 • Nursing Assessment, 1372 • Nursing Management, 1372

Nystagmus, 1373 Infantile Glaucoma, 1373 • Nursing Assessment, 1373 • Nursing Management, 1373

Congenital Cataract, 1373 • Nursing Assessment, 1373 • Nursing Management, 1374

Retinopathy of Prematurity, 1374 • Nursing Assessment, 1374 • Nursing Management, 1374

Visual Impairment, 1374 • Nursing Assessment, 1375 •

Nursing Management, 1375 Infectious and Inflammatory Disorders of the Ears, 1376 Acute Otitis Media, 1376 • Pathophysiology, 1376 • Therapeutic Management, 1376 • Nursing Assessment, 1377 • Nursing Management, 1378

xx   Contents

Otitis Media With Effusion, 1379 • Nursing Assessment,

1379 • Nursing Management, 1380 Otitis Externa, 1381 • Nursing Assessment, 1381 • Nursing Management, 1381 Hearing Loss and Deafness, 1381 Nursing Assessment, 1383 • Nursing Management, 1383 CHAPTER 40 Nursing

Care of the Child With a Respiratory Disorder  1388 Variations in Pediatric Anatomy and Physiology, 1389 Nose, 1389 • Throat, 1389 • Trachea, 1389 • Lower Respiratory Structures, 1390 • Chest Wall, 1390 • Metabolic Rate and Oxygen Need, 1390 Common Medical Treatments, 1391 Nursing Process Overview for the Child With a Respiratory Disorder, 1394 Acute Infectious Disorders, 1404 Common Cold, 1404 • Nursing Assessment, 1404 • Nursing Management, 1404 Sinusitis, 1407 • Nursing Assessment, 1407 • Nursing Management, 1407 Influenza, 1407 • Nursing Assessment, 1407 • Nursing Management, 1408 Pharyngitis, 1408 • Nursing Assessment, 1408 • Nursing Management, 1409 Tonsillitis, 1409 • Nursing Assessment, 1409 • Nursing Management, 1409 Infectious Mononucleosis, 1410 • Nursing Assessment, 1410 • Nursing Management, 1410

Laryngitis, 1410 Croup, 1410 • Nursing Assessment, 1411 • Nursing Management, 1411

Epiglottitis, 1411 • Nursing Assessment, 1412 • Nursing Management, 1412

Bronchiolitis (Respiratory Syncytial Virus), 1412 •

Pathophysiology, 1412 • Therapeutic Management, 1412 • Nursing Assessment, 1412 • Nursing Management, 1413 Pneumonia, 1414 • Nursing Assessment, 1415 • Nursing Management, 1416 Bronchitis, 1417 • Nursing Assessment, 1417 • Nursing Management, 1417 Tuberculosis, 1417 • Nursing Assessment, 1417 • Nursing Management, 1418 Acute Noninfectious Disorders, 1418 Epistaxis, 1418 • Nursing Assessment, 1418 • Nursing Management, 1418 Foreign Body Aspiration, 1418 • Nursing Assessment, 1419 • Nursing Management, 1419 Acute Respiratory Distress Syndrome, 1419 • Nursing Assessment, 1419 • Nursing Management, 1419 Pneumothorax, 1420 • Nursing Assessment, 1421 • Nursing Management, 1421 Chronic Respiratory Disorders, 1421 Allergic Rhinitis, 1421 • Pathophysiology, 1422 • Nursing Assessment, 1422 • Nursing Management, 1423 Asthma, 1423 • Pathophysiology, 1424 • Therapeutic Management, 1425 • Nursing Assessment, 1426 • Nursing Management, 1427 Chronic Lung Disease, 1432 • Nursing Assessment, 1432 • Nursing Management, 1432 Cystic Fibrosis, 1432 • Pathophysiology, 1433 • Therapeutic Management, 1433 • Nursing Assessment, 1433 • Nursing Management, 1435 Apnea, 1439 • Nursing Assessment, 1439 • Nursing Management, 1439 Tracheostomy, 1440 Nursing Assessment, 1440 • Nursing Management, 1441

CHAPTER 41 Nursing

Care of the Child With a Cardiovascular Disorder  1447 Variations in Pediatric Anatomy and Physiology, 1448 Circulatory Changes From Gestation to Birth, 1448 • Structural and Functional Differences, 1448 Common Medical Treatments, 1449 Nursing Process Overview for the Child With a Cardiovascular Disorder, 1453 Congenital Heart Disease, 1459 Pathophysiology, 1459 • Therapeutic Management, 1464

Disorders With Decreased Pulmonary Blood Flow, 1464 • Tetralogy of Fallot, 1467 • Pathophysiology,

1467 • Nursing Assessment, 1467 • Tricuspid Atresia, 1468 • Pathophysiology, 1468 • Nursing Assessment, 1469

Disorders With Increased Pulmonary Flow, 1469 •

Atrial Septal Defect, 1470 • Pathophysiology, 1470 • Nursing Assessment, 1470 • Ventricular Septal Defect, 1470 • Pathophysiology, 1470 • Nursing Assessment, 1471 • Atrioventricular Canal Defect, 1471 • Pathophysiology, 1471 • Nursing Assessment, 1471 • Patent Ductus Arteriosus, 1472 • Pathophysiology, 1472 • Nursing Assessment, 1472 Obstructive Disorders, 1473 • Coarctation of the Aorta, 1473 • Pathophysiology, 1473 • Nursing Assessment, 1473 • Aortic Stenosis, 1474 • Pathophysiology, 1474 • Nursing Assessment, 1474 • Pulmonary Stenosis, 1474 • Pathophysiology, 1474 • Nursing Assessment, 1475 Mixed Defects, 1475 • Transposition of the Great Vessels (Arteries), 1475 • Pathophysiology, 1475 • Nursing Assessment, 1476 • Total Anomalous Pulmonary Venous Connection, 1476 • Pathophysiology, 1476 • Nursing Assessment, 1477 • Truncus Arteriosus, 1477 • Pathophysiology, 1477 • Nursing Assessment, 1477 • Hypoplastic Left Heart Syndrome, 1477 • Pathophysiology, 1478 • Nursing Assessment, 1478 • Nursing Management of the Child With Congenital Heart Disease, 1478 Acquired Cardiovascular Disorders, 1482 Heart Failure, 1482 • Pathophysiology, 1482 • Therapeutic Management, 1482 • Nursing Assessment, 1483 • Nursing Management, 1484 Infective Endocarditis, 1485 • Nursing Assessment, 1485 • Nursing Management, 1485 Acute Rheumatic Fever, 1486 • Nursing Assessment, 1486 • Nursing Management, 1486 Cardiomyopathy, 1486 • Nursing Assessment, 1487 • Nursing Management, 1487 Hypertension, 1487 • Pathophysiology, 1488 • Nursing Assessment, 1488 • Nursing Management, 1488 Kawasaki Disease, 1489 • Pathophysiology, 1489 • Nursing Assessment, 1489 • Nursing Management, 1490 Hyperlipidemia, 1490 • Pathophysiology, 1490 • Therapeutic Management, 1490 • Nursing Assessment, 1491 • Nursing Management, 1491 Heart Transplantation, 1491 Surgical Procedure and Postoperative Therapeutic Management, 1492 • Nursing Management, 1492 CHAPTER 42 Nursing

Care of the Child With a Gastrointestinal Disorder  1496 Variations in Pediatric Anatomy and Physiology, 1497 Mouth, 1497 • Esophagus, 1497 • Stomach, 1497 • Intestines, 1497 • Biliary System, 1497 • Fluid Balance and Losses, 1497 Common Medical Treatments, 1498 Nursing Process Overview for the Child With a Gastrointestinal Disorder, 1498

Contents   xxi Structural Anomalies of the Gastrointestinal Tract, 1509 Cleft Lip and Palate, 1509 • Pathophysiology, 1510 • Therapeutic Management, 1510 • Nursing Assessment, 1510 • Nursing Management, 1511 Anorectal Malformations, 1512 • Nursing Assessment, 1512 • Nursing Management, 1512 Meckel Diverticulum, 1512 • Nursing Assessment, 1513 • Nursing Management, 1513 Inguinal and Umbilical Hernias, 1513 • Inguinal Hernia, 1513 • Umbilical Hernia, 1514 Acute Gastrointestinal Disorders, 1514 Dehydration, 1514 • Nursing Assessment, 1514 • Nursing Management, 1515 Vomiting, 1516 • Nursing Assessment, 1516 • Nursing Management, 1517 Diarrhea, 1517 • Pathophysiology, 1517 • Nursing Assessment, 1518 • Nursing Management, 1518 Oral Candidiasis (Thrush), 1520 • Nursing Assessment, 1520 • Nursing Management, 1521 Oral Lesions, 1521 • Nursing Assessment, 1521 • Nursing Management, 1521 Hypertrophic Pyloric Stenosis, 1522 • Nursing Assessment, 1523 • Nursing Management, 1523 Intussusception, 1523 • Nursing Assessment, 1524 • Nursing Management, 1524 Malrotation and Volvulus, 1524 • Nursing Assessment, 1524 • Nursing Management, 1524 Appendicitis, 1525 • Pathophysiology, 1525 • Therapeutic Management, 1525 • Nursing Assessment, 1525 • Nursing Management, 1526 Chronic Gastrointestinal Disorders, 1526 Gastroesophageal Reflux, 1526 • Pathophysiology, 1526 • Therapeutic Management, 1527 • Nursing Assessment, 1527 • Nursing Management, 1528 Peptic Ulcer Disease, 1528 • Therapeutic Management, 1529 • Nursing Assessment, 1529 • Nursing Management, 1529 Constipation and Encopresis, 1530 • Pathophysiology, 1530 • Therapeutic Management, 1531 • Nursing Assessment, 1531 • Nursing Management, 1531

Hirschsprung Disease (Congenital Aganglionic Megacolon), 1532 • Therapeutic Management, 1532 • Nursing Assessment, 1533 • Nursing Management, 1533

Short Bowel Syndrome, 1533 • Therapeutic

Management, 1534 • Nursing Assessment, 1534 • Nursing Management, 1534 Inflammatory Bowel Disease, 1534 • Therapeutic Management, 1534 • Nursing Assessment, 1536 • Nursing Management, 1536 Celiac Disease, 1537 • Nursing Assessment, 1537 • Nursing Management, 1537 Recurrent Abdominal Pain, 1538 • Pathophysiology, 1539 • Nursing Assessment, 1539 • Nursing Management, 1539 Hepatobiliary Disorders, 1540 Pancreatitis, 1540 • Nursing Assessment, 1540 • Nursing Management, 1540 Gallbladder Disease, 1541 • Nursing Assessment, 1541 • Nursing Management, 1541 Biliary Atresia, 1541 • Therapeutic Management, 1541 • Nursing Assessment, 1542 • Nursing Management, 1542 Hepatitis, 1542 • Therapeutic Management, 1542 • Nursing Assessment, 1544 • Nursing Management, 1544 Cirrhosis and Portal Hypertension, 1544 • Nursing Assessment, 1544 • Nursing Management, 1545 Liver Transplantation, 1545 • Nursing Assessment, 1545 • Nursing Management, 1545

CHAPTER 43 Nursing

Care of the Child With a Genitourinary Disorder  1549 Variations in Pediatric Anatomy and Physiology, 1550 Structural Differences, 1550 • Urinary Concentration, 1550 • Urine Output, 1550 • Reproductive Organ Maturity, 1550 Common Medical Treatments, 1550 Nursing Process Overview for the Child With a Genitourinary Disorder, 1551 Urinary Tract and Renal Disorders, 1561 Structural Disorders, 1561 • Bladder Exstrophy, 1561 • Hypospadias/Epispadias, 1562 • Nursing Assessment, 1563 • Nursing Management, 1563 • Obstructive Uropathy, 1565 • Nursing Assessment, 1565 • Nursing Management, 1565 • Hydronephrosis, 1565 • Nursing Assessment, 1565 • Nursing Management, 1566 • Vesicoureteral Reflux, 1566 • Nursing Assessment, 1566 • Nursing Management, 1567 • Urinary Tract Infection, 1567 • Pathophysiology, 1567 • Therapeutic Management, 1568 • Nursing Assessment, 1568 • Nursing Management, 1569 • Enuresis, 1569 • Nursing Assessment, 1570 • Nursing Management, 1570

Acquired Disorders Resulting in Altered Renal Function, 1571 • Nephrotic Syndrome, 1571 •

Pathophysiology, 1571 • Therapeutic Management, 1572 • Nursing Assessment, 1572 • Nursing Management, 1572 • Acute Poststreptococcal Glomerulonephritis, 1573 • Nursing Assessment, 1573 • Nursing Management, 1574 • Hemolytic-Uremic Syndrome, 1574 • Nursing Assessment, 1574 • Nursing Management, 1575 Renal Failure, 1575 • Acute Renal Failure, 1575 • Nursing Assessment, 1576 • Nursing Management, 1576 • End-Stage Renal Disease, 1576 • Nursing Assessment, 1576 • Nursing Management, 1577 Dialysis and Transplantation, 1578 • Peritoneal Dialysis, 1578 • Hemodialysis, 1578 • Nursing Assessment, 1579 • Nursing Management, 1580 Renal Transplantation, 1580 • Nursing Assessment, 1581 • Nursing Management, 1581 Reproductive Organ Disorders, 1582 Female Disorders, 1582 • Labial Adhesions, 1582 • Nursing Assessment, 1582 • Nursing Management, 1582 • Vulvovaginitis, 1582 • Nursing Assessment, 1582 • Nursing Management, 1582 Male Disorders, 1582 • Phimosis and Paraphimosis, 1583 • Nursing Assessment, 1583 • Nursing Management, 1583 • Circumcision, 1583 • Nursing Assessment, 1584 • Nursing Management, 1584 • Cryptorchidism, 1585 • Nursing Assessment, 1585 • Nursing Management, 1585 • Hydrocele and Varicocele, 1585 • Nursing Assessment, 1585 • Nursing Management, 1585 • Testicular Torsion, 1585 • Nursing Assessment, 1585 • Nursing Management, 1585 • Epididymitis, 1586 • Nursing Assessment, 1586 • Nursing Management, 1586 CHAPTER 44 Nursing

Care of the Child With a Neuromuscular Disorder  1589 Variations in Pediatric Anatomy and Physiology, 1590 Brain and Spinal Cord Development, 1590 • Myelinization, 1590 • Muscular Development, 1590 Common Medical Treatments, 1590 Nursing Process Overview for the Child With a Neuromuscular Disorder, 1590 Congenital Neuromuscular Disorders, 1600 Neural Tube Defects, 1600 • Spina Bifida Occulta, 1600 • Nursing Assessment, 1600 • Nursing Management, 1601 • Meningocele, 1601 • Nursing Assessment, 1601 • Nursing Management, 1601 • Myelomeningocele, 1601 •

xxii   Contents Pathophysiology, 1602 • Therapeutic Management, 1602 • Nursing Assessment, 1602 • Nursing Management, 1603 • Muscular Dystrophy, 1606 • Pathophysiology, 1606 • Therapeutic Management, 1607 • Nursing Assessment, 1608 • Nursing Management, 1608 • Spinal Muscular Atrophy, 1610 • Nursing Assessment, 1611 • Nursing Management, 1611 • Cerebral Palsy, 1612 • Pathophysiology, 1612 • Therapeutic Management, 1613 • Nursing Assessment, 1615 • Nursing Management, 1616 Acquired Neuromuscular Disorders, 1617 Spinal Cord Injury, 1617 • Nursing Assessment, 1617 • Nursing Management, 1618 Guillain-Barré Syndrome, 1618 • Therapeutic Management, 1618 • Nursing Assessment, 1618 • Nursing Management, 1619 Myasthenia Gravis, 1619 • Nursing Assessment, 1619 • Nursing Management, 1619 Dermatomyositis, 1620 • Nursing Assessment, 1620 • Nursing Management, 1620 Botulism, 1620 Nursing Assessment, 1620 • Nursing Management, 1621 CHAPTER 45 Nursing

Care of the Child With a Musculoskeletal Disorder  1625 Variations in Pediatric Anatomy and Physiology, 1625 Myelinization, 1626 • Muscle Development, 1626 • Skeletal Development, 1626 • Growth Plate, 1626 • Bone Healing, 1627 • Positional Alterations, 1627 Common Medical Treatments, 1628 Casts, 1628 • Traction, 1628 • External Fixation, 1628 Nursing Process Overview for the Child With a Musculoskeletal Disorder, 1628 Congenital and Developmental Disorders, 1642 Pectus Excavatum, 1643 • Therapeutic Management, 1643 • Nursing Assessment, 1643 • Nursing Management, 1643 Limb Deficiencies, 1643 • Nursing Assessment, 1644 • Nursing Management, 1644 Polydactyly/Syndactyly, 1644 • Nursing Assessment, 1644 • Nursing Management, 1644 Metatarsus Adductus, 1644 • Nursing Assessment, 1645 • Nursing Management, 1645 Congenital Clubfoot, 1645 • Therapeutic Management, 1645 • Nursing Assessment, 1645 • Nursing Management, 1645 Osteogenesis Imperfecta, 1645 • Therapeutic Management, 1646 • Nursing Assessment, 1647 • Nursing Management, 1647 Developmental Dysplasia of the Hip, 1647 • Pathophysiology, 1647 • Therapeutic Management, 1648 • Nursing Assessment, 1648 • Nursing Management, 1648 Tibia Vara (Blount Disease), 1650 • Nursing Assessment, 1651 • Nursing Management, 1651 Torticollis, 1651 • Nursing Assessment, 1651 • Nursing Management, 1651 Acquired Disorders, 1652 Rickets, 1652 • Therapeutic Management, 1652 • Nursing Assessment, 1652 • Nursing Management, 1653 Slipped Capital Femoral Epiphysis, 1653 • Therapeutic Management, 1653 • Nursing Assessment, 1653 • Nursing Management, 1653 Legg-Calvé-Perthes Disease, 1653 • Therapeutic Management, 1653 • Nursing Assessment, 1654 • Nursing Management, 1654 Osteomyelitis, 1654 • Therapeutic Management, 1654 • Nursing Assessment, 1654 • Nursing Management, 1655

Septic Arthritis, 1655 • Nursing Assessment, 1655 • Nursing Management, 1655 Transient Synovitis of the Hip, 1656 • Nursing Assessment, 1656 • Nursing Management, 1656 Scoliosis, 1656 • Pathophysiology, 1656 • Therapeutic Management, 1656 • Nursing Assessment, 1657 • Nursing Management, 1658 Injuries, 1659 Fracture, 1660 • Pathophysiology, 1660 • Therapeutic Management, 1660 • Nursing Assessment, 1660 • Nursing Management, 1663 Sprains, 1664 • Nursing Assessment, 1664 • Nursing Management, 1664 Overuse Syndromes, 1665 • Nursing Assessment, 1665 • Nursing Management, 1665 Radial Head Subluxation, 1666 • Nursing Assessment, 1666 • Nursing Management, 1666 CHAPTER 46 Nursing

Care of the Child With an Integumentary Disorder  1670 Variations in Pediatric Anatomy and Physiology, 1671 Differences in the Skin Between Children and Adults, 1671 • Differences in Dark-Skinned Children, 1671 • Sebaceous and Sweat Glands, 1671 Common Medical Treatments, 1671 Nursing Process Overview for the Child With an Integumentary Disorder, 1674 Infectious Disorders, 1675 Bacterial Infections, 1675 • Nursing Assessment, 1678 • Nursing Management, 1678 Fungal Infections, 1679 • Nursing Assessment, 1680 • Nursing Management, 1680 Inflammatory Skin Conditions, 1682 Diaper Dermatitis, 1682 • Nursing Assessment, 1682 • Nursing Management, 1682 Atopic Dermatitis, 1683 • Pathophysiology, 1683 • Nursing Assessment, 1683 • Nursing Management, 1684 Contact Dermatitis, 1684 • Nursing Assessment, 1685 • Nursing Management, 1685 Erythema Multiforme, 1686 • Nursing Assessment, 1686 • Nursing Management, 1686 Urticaria, 1686 • Nursing Assessment, 1687 • Nursing Management, 1687 Seborrhea, 1687 • Nursing Assessment, 1687 • Nursing Management, 1688 Psoriasis, 1688 • Nursing Assessment, 1688 • Nursing Management, 1688 Acne, 1688 Acne Neonatorum, 1689 • Nursing Assessment, 1689 • Nursing Management, 1689 Acne Vulgaris, 1689 • Pathophysiology, 1689 • Therapeutic Management, 1689 • Nursing Assessment, 1689 • Nursing Management, 1690 Injuries, 1691 Pressure Ulcers, 1691 • Nursing Assessment, 1691 • Nursing Management, 1691 Minor Injuries, 1691 • Nursing Assessment, 1691 • Nursing Management, 1691 Burns, 1691 • Pathophysiology, 1692 • Therapeutic Management, 1692 • Nursing Assessment, 1693 • Nursing Management, 1694 Sunburn, 1699 • Nursing Assessment, 1699 • Nursing Management, 1700 Cold Injury, 1700 • Nursing Assessment, 1700 • Nursing Management, 1700

Contents   xxiii

Human and Animal Bites, 1700 • Nursing Assessment, 1700 • Nursing Management, 1700

Insect Stings and Spider Bites, 1701 • Nursing Assessment, 1701 • Nursing Management, 1701

CHAPTER 47 Nursing

Care of the Child With a Hematologic Disorder  1705 Variations in Pediatric Anatomy and Physiology, 1707 Red Blood Cell Production, 1707 • Hemoglobin, 1707 • Iron, 1707 Common Medical Treatments, 1707 Nursing Process Overview for the Child With a Hematologic Disorder, 1707 Anemia, 1712 Iron-Deficiency Anemia, 1717 • Therapeutic Management, 1717 • Nursing Assessment, 1717 • Nursing Management, 1718

Other Nutritional Causes of Anemia, 1719 Lead Poisoning, 1719 • Nursing Assessment, 1719 • Nursing Management, 1720

Aplastic Anemia, 1720 • Nursing Assessment, 1720 •

Nursing Management, 1721

Hemoglobinopathies, 1721 • Sickle Cell Disease, 1721 •

Pathophysiology, 1722 • Therapeutic Management, 1722 • Nursing Assessment, 1722 • Nursing Management, 1725 • Thalassemia, 1727 • Therapeutic Management, 1728 • Nursing Assessment, 1728 • Nursing Management, 1728 • Glucose-6-Phosphate Dehydrogenase Deficiency, 1729 • Nursing Assessment, 1729 • Nursing Management, 1729 Clotting Disorders, 1729 Idiopathic Thrombocytopenia Purpura, 1731 • Nursing Assessment, 1731 • Nursing Management, 1731 Henoch-Schönlein Purpura, 1731 • Nursing Assessment, 1731 • Nursing Management, 1732 Disseminated Intravascular Coagulation, 1732 • Nursing Assessment, 1732 • Nursing Management, 1732 Hemophilia, 1733 • Therapeutic Management, 1733 • Nursing Assessment, 1733 • Nursing Management, 1734 Von Willebrand disease, 1735 • Nursing Assessment, 1735 • Nursing Management, 1735 CHAPTER 48 Nursing

Care of the Child With an Immunologic Disorder  1738 Variations in Pediatric Anatomy and Physiology, 1739 Lymph System, 1739 • Phagocytosis, 1739 • Cellular Immunity, 1740 • Humoral Immunity, 1740 Common Medical Treatments, 1740 Nursing Process Overview for the Child With an Immunologic Disorder, 1742 Primary Immunodeficiencies, 1745 Hypogammaglobulinemia, 1745 • Nursing Assessment, 1748 • Nursing Management, 1749 Wiskott-Aldrich Syndrome, 1750 • Nursing Assessment, 1750 • Nursing Management, 1751 Severe Combined Immune Deficiency, 1751 • Nursing Assessment, 1751 • Nursing Management, 1751 Secondary Immunodeficiencies, 1751 HIV Infection, 1751 • Pathophysiology, 1752 • Therapeutic Management, 1753 • Nursing Assessment, 1753 • Nursing Management, 1753 Autoimmune Disorders, 1756 Systemic Lupus Erythematosus, 1756 • Pathophysiology, 1756 • Therapeutic Management, 1756 • Nursing Assessment, 1756 • Nursing Management, 1757

Juvenile Idiopathic Arthritis, 1757 • Nursing

Assessment, 1758 • Nursing Management, 1758 Allergy and Anaphylaxis, 1759 Food Allergies, 1759 • Therapeutic Management, 1760 • Nursing Assessment, 1760 • Nursing Management, 1760 Anaphylaxis, 1761 • Nursing Assessment, 1761 • Nursing Management, 1761 Latex Allergy, 1762 • Nursing Assessment, 1762 • Nursing Management, 1763 CHAPTER 49 Nursing

Care of the Child With an Endocrine Disorder  1768 Variations in Anatomy and Physiology, 1769 Hormone Production and Secretion, 1769 Common Medical Treatments, 1769 Nursing Process Overview for the Child With an Endocrine Disorder, 1770 Pituitary Disorders, 1778 Growth Hormone Deficiency, 1778 • Pathophysiology, 1778 • Therapeutic Management, 1778 • Nursing Assessment, 1782 • Nursing Management, 1783 Hyperpituitarism (Pituitary Gigantism), 1784 • Nursing Assessment, 1784 • Nursing Management, 1784 Precocious Puberty, 1784 • Pathophysiology, 1784 • Therapeutic Management, 1785 • Nursing Assessment, 1785 • Nursing Management, 1785 Delayed Puberty, 1786 • Nursing Assessment, 1786 • Nursing Management, 1786 Diabetes Insipidus, 1786 • Pathophysiology, 1786 • Therapeutic Management, 1787 • Nursing Assessment, 1787 • Nursing Management, 1787

Syndrome of Inappropriate Antidiuretic Hormone, 1788 • Nursing Assessment, 1788 • Nursing Management, 1789

Disorders of Thyroid Function, 1789

Congenital Hypothyroidism, 1789 • Pathophysiology,

1789 • Therapeutic Management, 1789 • Nursing Assessment, 1790 • Nursing Management, 1790 Acquired Hypothyroidism, 1791 • Nursing Assessment, 1791 • Nursing Management, 1792 Hyperthyroidism, 1792 • Nursing Assessment, 1792 • Nursing Management, 1793 Disorders Related to Parathyroid Gland Function, 1793 Disorders Related to Adrenal Gland Function, 1793 Congenital Adrenal Hyperplasia, 1795 • Pathophysiology, 1796 • Therapeutic Management, 1796 • Nursing Assessment, 1796 • Nursing Management, 1797 Polycystic Ovary Syndrome, 1798 Nursing Assessment, 1798 • Nursing Management, 1798 Diabetes Mellitus, 1798 Pathophysiology, 1799 • Therapeutic Management, 1801 • Nursing Assessment, 1804 • Nursing Management, 1805 CHAPTER 50 Nursing

Care of the Child With a Neoplastic Disorder  1813 Childhood Cancer Versus Adult Cancer, 1814 Common Medical Treatments, 1814 Chemotherapy, 1816 • Radiation Therapy, 1822 • Hematopoietic Stem Cell Transplantation, 1822 Nursing Process Overview for the Child With a Neoplastic Disorder, 1823 Leukemia, 1838 Acute Lymphoblastic Leukemia, 1838 • Pathophysiology, 1839 • Therapeutic Management, 1839 • Nursing Assessment, 1840 • Nursing Management, 1840

xxiv   Contents

Acute Myelogenous Leukemia, 1841 • Nursing

Assessment, 1841 • Nursing Management, 1841 Lymphomas, 1841 Hodgkin Disease, 1842 • Nursing Assessment, 1842 • Nursing Management, 1843 Non-Hodgkin Lymphoma, 1843 • Nursing Assessment, 1843 • Nursing Management, 1843 Brain Tumors, 1843 Pathophysiology, 1843 • Therapeutic Management, 1843 • Nursing Assessment, 1844 • Nursing Management, 1845 Neuroblastoma, 1845 Nursing Assessment, 1846 • Nursing Management, 1846 Bone and Soft Tissue Tumors, 1847 Osteosarcoma, 1847 • Nursing Assessment, 1847 • Nursing Management, 1847 Ewing Sarcoma, 1847 • Nursing Assessment, 1848 • Nursing Management, 1848 Rhabdomyosarcoma, 1848 • Nursing Assessment, 1848 • Nursing Management, 1849 Wilms Tumor, 1849 Therapeutic Management, 1850 • Nursing Assessment, 1850 • Nursing Management, 1851 Retinoblastoma, 1851 Nursing Assessment, 1851 • Nursing Management, 1852 Screening for Reproductive Cancers in Adolescents, 1852

Cervical Cancer, 1852 Testicular Cancer, 1852

CHAPTER 51 Nursing

Care of the Child With a Genetic Disorder  1856 Nurse’s Role and Responsibilities, 1857 Common Medical Treatments, 1857 Nursing Process Overview for the Child With a Genetic Disorder, 1857 Common Chromosomal Abnormalities, 1866 Trisomy 21 (Down Syndrome), 1866 • Pathophysiology, 1868 • Therapeutic Management, 1868 • Nursing Assessment, 1870 • Nursing Management, 1871 Trisomy 18 and Trisomy 13, 1873 • Nursing Assessment, 1873 • Nursing Management, 1873 Turner Syndrome, 1874 • Nursing Assessment, 1874 • Nursing Management, 1874 Klinefelter Syndrome, 1875 • Nursing Assessment, 1875 • Nursing Management, 1875 Fragile X Syndrome, 1876 • Nursing Assessment, 1876 • Nursing Management, 1876 Neurocutaneous Disorders, 1876 Neurofibromatosis, 1877 • Nursing Assessment, 1877 • Nursing Management, 1879 Other Genetic Disorders, 1879 Inborn Errors of Metabolism, 1879 Nursing Assessment, 1879 • Nursing Management, 1882 CHAPTER 52 Nursing

Care of the Child With a Cognitive or Mental Health Disorder  1889 Effects of Mental Health Issues on Health and Development, 1890 Common Medical Treatments, 1890 Nursing Process Overview for the Child With a Mental Health Disorder, 1893 Developmental and Behavioral Disorders, 1894 Learning Disabilities, 1894 • Therapeutic Management, 1898 • Nursing Assessment, 1898 • Nursing Management, 1899 Intellectual Disability, 1899 • Pathophysiology, 1899 •

Therapeutic Management, 1899 • Nursing Assessment, 1899 • Nursing Management, 1900 Autism Spectrum Disorder, 1900 • Pathophysiology, 1900 • Therapeutic Management, 1900 • Nursing Assessment, 1900 • Nursing Management, 1901 Attention Deficit/Hyperactivity Disorder, 1901 • Pathophysiology, 1901 • Therapeutic Management, 1901 • Nursing Assessment, 1902 • Nursing Management, 1903 Tourette Syndrome, 1903 Nursing Assessment, 1903 • Nursing Management, 1903 Eating Disorders, 1904 Nursing Assessment, 1904 • Nursing Management, 1904 Mood Disorders, 1905 Pathophysiology, 1905 • Therapeutic Management, 1905 • Nursing Assessment, 1905 • Nursing Management, 1906 Anxiety Disorders, 1907 Types of Anxiety Disorders, 1907 • Pathophysiology, 1907 • Therapeutic Management, 1907 • Nursing Assessment, 1908 • Nursing Management, 1908 Abuse and Violence, 1908 Child Maltreatment, 1908 • Nursing Assessment, 1909 • Nursing Management, 1910 Münchausen Syndrome by Proxy, 1910 • Nursing Assessment, 1910 • Nursing Management, 1910 Substance Abuse, 1910 • Nursing Assessment, 1911 • Nursing Management, 1911 CHAPTER 53 Nursing

Care During a Pediatric Emergency 1915 Common Medical Treatments, 1916 Nursing Process Overview for the Child in an Emergency Situation, 1916 Nursing Management of Children in Emergencies, 1927 Respiratory Arrest, 1928 Shock, 1938 Pathophysiology, 1938 • Types of Shock, 1938 • Nursing Assessment, 1939 • Nursing Management, 1940 Cardiac Arrhythmias and Arrest, 1941 Pathophysiology, 1942 • Nursing Assessment, 1943 • Nursing Management, 1944 Near Drowning, 1946 Pathophysiology, 1946 • Nursing Assessment, 1947 • Nursing Management, 1948 Poisoning, 1948 Nursing Assessment, 1948 • Nursing Management, 1949 Trauma, 1949 Nursing Assessment, 1949 • Nursing Management, 1950

Standard Laboratory Values  1955 Clinical Paths  1959 APPENDIX C Cervical Dilation Chart  1964 APPENDIX D Weight Conversion Charts   1965 APPENDIX E Breast-Feeding and Medication Use 1967 APPENDIX F Growth Charts  1969 APPENDIX G Denver II Developmental ­Assessment  1980 APPENDIX H Blood Pressure Charts for Children and Adolescents  1982 APPENDIX I Down Syndrome Health Care ­Guidelines  1986 Index 1988 APPENDIX A



APPENDIX B

Contents in Brief INTRODUCTION TO MATERNITY AND PEDIATRIC NURSING 3

UNIT ONE CHAPTER 1

Perspectives on Maternal and Child Health Care   5

CHAPTER 2

Core Concepts of Maternal and Child Health Care and Community-Based Care   58

UNIT TWO

WOMEN’S HEALTH THROUGHOUT THE LIFE SPAN  89

CHAPTER 3

Anatomy and Physiology of the Reproductive System  91 Common Reproductive Issues   107 Sexually Transmitted Infections  162 Disorders of the Breasts  198 Benign Disorders of the Female Reproductive Tract  226 Cancers of the Female Reproductive Tract   250 Violence and Abuse   278

CHAPTER 4 CHAPTER 5 CHAPTER 6 CHAPTER 7 CHAPTER 8 CHAPTER 9

UNIT THREE PREGNANCY  305 CHAPTER 10 CHAPTER 11 CHAPTER 12

Fetal Development and Genetics   307 Maternal Adaptation During Pregnancy   334 Nursing Management During Pregnancy  363

UNIT FOUR LABOR AND BIRTH  415 CHAPTER 13 Labor and Birth Process   417 CHAPTER 14 Nursing Management During Labor and Birth  444

UNIT FIVE CHAPTER 15 CHAPTER 16

POSTPARTUM PERIOD  489 Postpartum Adaptations   491 Nursing Management During the Postpartum Period  508

UNIT SIX CHAPTER 17 CHAPTER 18

THE NEWBORN  547 Newborn Transitioning  549 Nursing Management of the Newborn   567

UNIT SEVEN CHILDBEARING AT RISK  623 Nursing Management of Pregnancy at Risk: Pregnancy-Related Complications  625 Nursing Management of the Pregnancy at Risk: Selected Health Conditions and Vulnerable Populations   670 CHAPTER 21 Nursing Management of Labor and Birth at Risk  728 CHAPTER 22 Nursing Management of the Postpartum Woman at Risk  768 CHAPTER 19

CHAPTER 20

UNIT EIGHT THE NEWBORN AT RISK  799 CHAPTER 23 CHAPTER 24

Nursing Care of the Newborn With Special Needs  801 Nursing Management of the Newborn at Risk: Acquired and Congenital Newborn Conditions  833

UNIT NINE HEALTH PROMOTION OF THE GROWING CHILD AND FAMILY  883 CHAPTER 25 CHAPTER 26 CHAPTER 27 CHAPTER 28 CHAPTER 29



Growth Growth Growth Growth Growth

and and and and and

Development Development Development Development Development

of of of of of

the the the the the

Newborn and Infant  885 Toddler  920 Preschooler  950 School-Age Child  976 Adolescent  1003

Contents in Brief

UNIT TEN CHAPTER 30 CHAPTER 31 CHAPTER 32 CHAPTER 33 CHAPTER 34 CHAPTER 35 CHAPTER 36

CHILDREN AND THEIR FAMILIES  1035

Atraumatic Care of Children and Families  1037 Health Supervision  1051 Health Assessment of Children  1085 Caring for Children in Diverse Settings  1126 Caring for the Special Needs Child  1163 Key Pediatric Nursing Interventions  1184 Pain Management in Children  1215

UNIT ELEVEN NURSING CARE OF THE CHILD WITH A HEALTH DISORDER 1255 CHAPTER 37 CHAPTER 38 CHAPTER 39 CHAPTER 40 CHAPTER 41 CHAPTER 42 CHAPTER 43 CHAPTER 44 CHAPTER 45 CHAPTER 46 CHAPTER 47 CHAPTER 48 CHAPTER 49 CHAPTER 50 CHAPTER 51 CHAPTER 52 CHAPTER 53



Nursing Nursing Nursing Nursing Nursing Nursing Nursing Nursing Nursing Nursing Nursing Nursing Nursing Nursing Nursing Nursing Nursing

Care Care Care Care Care Care Care Care Care Care Care Care Care Care Care Care Care

APPENDIX A

of the Child With an Infectious or Communicable Disorder  1257 of the Child With a Neurologic Disorder  1302 of the Child With a Disorder of the Eyes or Ears  1354 of the Child With a Respiratory Disorder  1388 of the Child With a Cardiovascular Disorder  1447 of the Child With a Gastrointestinal Disorder  1496 of the Child With a Genitourinary Disorder  1549 of the Child With a Neuromuscular Disorder  1589 of the Child With a Musculoskeletal Disorder  1625 of the Child With an Integumentary Disorder  1670 of the Child With a Hematologic Disorder  1705 of the Child With an Immunologic Disorder  1738 of the Child With an Endocrine Disorder  1768 of the Child With a Neoplastic Disorder  1813 of the Child With a Genetic Disorder  1856 of the Child With a Cognitive or Mental Health Disorder  1889 During a Pediatric Emergency  1915

Standard Laboratory Values  1955 Clinical Paths  1959 APPENDIX C Cervical Dilation Chart  1964 APPENDIX D Weight Conversion Charts   1965 APPENDIX E Breast-Feeding and Medication Use  1967 APPENDIX F Growth Charts  1969 APPENDIX G Denver II Developmental Assessment  1980 APPENDIX H Blood Pressure Charts for Children and Adolescents  1982 APPENDIX I Down Syndrome Health Care Guidelines  1986 APPENDIX B



Index 1988

unit

one

Introduction to Maternity and Pediatric Nursing

1 KEY TERMS assent certified nurse midwife (CNM) child abuse and neglect childhood mortality rate cultural competence culture discipline dissent Do not resuscitate (DNR) orders doula emancipated minor enculturation ethnicity ethnocentrism family family structure fetal mortality rate foster care infant mortality rate maternal–fetal conflict maternal mortality ratio mature minor morbidity mortality neonatal mortality neonatal mortality rate punishment religion resilience spirituality stem cells temperament

Perspectives on Maternal and Child Health Care Learning Objectives Upon completion of the chapter, you will be able to: 1. Define the key terms used in this chapter. 2. Analyze the key milestones in the history of maternal, newborn, and child health and health care. 3. Examine the evolution of maternal, newborn, and pediatric nursing. 4. Compare the past definitions of health and illness to the current definitions, as well as the measurements used to assess health and illness in children. 5. Assess the factors that affect maternal and child health. 6. Differentiate the structures, roles, and functions of the family and how they affect the health of women and children. 7. Evaluate how society and culture can influence the health of women, children, and families. 8. Appraise the health care barriers affecting women, children, and families. 9. Research the ethical and legal issues that may arise when caring for women, children, and families.

WOW

Words of Wisdom Sophia Greenly, a 38-year-old woman pregnant with her third child, comes to the prenatal clinic for a routine follow-up visit. Her mother, Betty, accompanies her because Sophia’s husband is out of town. Sophia lives with her husband and two children, ages 4 and 9. She works part-time as a lunch aide in the local elementary school. What factors may play a role in influencing the health of Sophia and her family?

Being pregnant and giving birth is like crossing a narrow bridge: people can accompany you to the bridge, and they can greet you on the other side, but you walk that bridge alone. And the journey doesn’t end there: children are the future of a society and special gifts to the world. Changes in our society and world require us to be attentive to and value them and their health.

6   U N I T 1   Introduction to Maternity and Pediatric Nursing

A person’s ability to lead a fulfilling life and to participate fully in society depends largely on his or her health status. This is especially true for women, who commonly are responsible for not only their own health, but also that of others: their children and families. Thus, it is important to concentrate on the health of women, children, and families. Although the overall health of children has improved and the rates of death and illness in some areas have decreased, the need to focus on the health of women and children remains. Habits and practices established during pregnancy and early childhood can have profound effects on a person’s health and illness throughout life. As a society, creating a population that cares about women, children, and families and promotes solid health care and lifestyle choices is crucial. Maternal and newborn nursing encompasses a wide scope of practice typically associated with childbearing. It includes care of the woman before pregnancy, care of the woman and her fetus during pregnancy, care of the woman after pregnancy, and care of the newborn, usually during the first 6 weeks after birth. The overall goal of maternal and newborn nursing is to promote and maintain optimal health of the woman and her family. Child health nursing, commonly referred to as pediatric nursing, involves the care of the child from infancy through adolescence. In the United States, the number of children under age 18 years is approximately 74.2 million, accounting for 24% of the population (Federal Interagency Forum on Child and Family Statistics, 2011). The overall goal of pediatric nursing practice is to promote and assist the child in maintaining optimal levels of health, while recognizing the influence of the family on the child’s well-being. This goal involves health promotion and disease and injury prevention as well as assisting with care during illness. The common thread in both of these is the care of the family. This chapter presents a general overview of the health care of women, children, and families and describes the major factors affecting maternal and child health. Nurses need to be knowledgeable about these concepts and factors to ensure that they provide professional care.

HISTORICAL DEVELOPMENT The health care of women and children has changed over the years due in part to changes in childbirth methods, devastating epidemics, social trends in our country, changes in the health care system, and federal and state regulations. By reviewing historical events, nurses can gain a better understanding of the current and future status of maternal and child health and how maternal and pediatric nursing care has evolved.

The History of Maternal and Newborn Health and Health Care Childbirth in colonial America was a difficult and dangerous experience. During the 17th and 18th centuries, women giving birth often died as a result of exhaustion, dehydration, infection, hemorrhage, or seizures (McIntosh, 2012). Approximately 50% of all children died before age 5 (Shanley, 2012), compared with the 0.06% infant mortality rate of today (Central Intelligence Agency, 2012). Women who labored and gave birth at home were traditionally attended to by relatives and midwives (see Evidence-Based Practice box). Centuries ago, “granny midwives” handled the normal birthing process for most women. They learned their skills through an apprenticeship with a more experienced midwife. Physicians usually were called only in extremely difficult cases, and all births took place at home. During the early 1900s, physicians attended about half the births in the United States. Midwives often cared for women who could not afford a doctor. Many women were attracted to hospitals because this showed affluence and they provided pain management, which was not available in home births. In the 1950s, “natural childbirth” practices advocating birth without medication and focusing on relaxation techniques were introduced. These techniques opened the door to childbirth education classes and helped bring the father back into the picture. Both partners could participate by taking an active role in pregnancy, childbirth, and parenting (Fig. 1.1). Box 1.1 shows a time line of childbirth in America. In many ways, childbirth practices in the United States have come full circle, as we see the return of nurse midwives and doulas. Today, childbirth choices are often based on what works best for the mother, child, and family.

The History of Child Health and Child Health Care In past centuries in the United States, the health of the country was poorer than it is today; mortality rates were high and life expectancy was short. Infectious diseases were rampant, and unsanitary food sources contributed to illness in children. Devastating epidemics of smallpox, diphtheria, scarlet fever, and measles hit children the hardest. As the end of the 19th century neared, doctors and scientists gained a better understanding of the root causes of illness. This knowledge helped fuel public health efforts such as the campaign for safe milk supply, which lead to pasteurizing milk and to dispensing free milk in some cities (The Maternal Child Health B ­ ureau [MCHB], 2012). Compulsory vaccination programs began during this time. In the late 1800s some states mandated smallpox vaccination as a condition of school attendance.



C h a p t e r 1   Perspectives on Maternal and Child Health Care    7

EVIDENCE-BASED PRACTICE 1.1

HOW DO WOMEN IN CHILDBIRTH RESPOND TO CONTINUOUS LABOR SUPPORT?

STUDY Throughout history, women have been helping other women in labor by providing emotional support, comfort measures, information, and advocacy. However, in recent years this practice has waned, and facilities frequently adhere to strict specific routines that may leave women feeling “dehumanized.” A study was done to assess the effects on mothers and their newborns of continuous, one-to-one intrapartum care in comparison to usual care. The study also evaluated routine practices and policies in the birth environment that might affect a woman’s autonomy, freedom of movement, and ability to cope with labor; who the caregiver was, whether or not a staff member of the facility; and when the support began, early or late in labor. All published and unpublished randomized clinical trials comparing continuous support ­during ­labor with usual care were examined. One author and one research assistant used standard ­methods for data collection and analysis and extracted the data independently. Clinical trial authors provided additional information. The researchers used relative risk for categorical data and weighted mean difference for continuous data. Sixteen trials from 11 countries involving 13,391 women were examined to provide the data.

Findings Women receiving continuous intrapartum support had a greater chance of a spontaneous vaginal delivery (including without forceps or vacuum extraction). They also had a slight decrease in the length of labor and required less analgesia during this time. These women also reported increased satisfaction with their labor and childbirth experience. Overall, the support, when provided by someone other than a facility staff member and initiated early in labor, proved to be more effective.

Nursing Implications Based on this research, it is clear that women in labor benefit from one-to-one support during labor. Nurses can use the information gained from this study to educate women about the importance of support persons during labor and delivery. Nurses can also act as client advocates in facilities where they work to foster an environment that encourages the use of support persons during the intrapartum period. The focus of nursing needs to be individualized, supportive, and collaborative with the family during their childbearing experience. In short, nurses should place the needs of the mother and her family first in providing a continuum of care. Although the study found that support is more effective when provided by someone other than a staff member, support from an individual is key. Assigning the same nurse to provide care to the couple throughout the birthing experience also fosters a one-to-one relationship that helps meet the couple’s needs and promotes feelings of security. By meeting the couple’s needs, the nurse is enhancing their birthing experience. Source: Hodnett, E. D., Gates, S., Hofmeyr, G. J., Sakala, C., & Weston, J. (2011). Continuous support for women during childbirth. Cochrane Database of Systematic Reviews 2011, 2. Art. No.: CD003766. DOI: 10.1002/14651858. CD003766.pub3.

These public health efforts led to a decrease in infant and child deaths (MCHB, 2012). In the late 19th and early 20th centuries, cities became healthier places to live due to urban public health improvements such as sanitation services and treated municipal water (MCHB, 2012). The threat of childhood diseases lessened with the discovery of penicillin and additional vaccine development (MCHB, 2012). Thus, by the end of the 20th century, unintentional injuries surpassed disease as the leading cause of death for children greater than 1 year old (Epstein, 2011). Technological advances have significantly affected all aspects of health care and led to increased survival rates in children. However, many children who survive

illnesses that were previously considered fatal are left with chronic disabilities. For example, before the 1960s, extremely premature infants did not survive because of the immaturity of their lungs. Mechanical ventilation and the use of medications to foster lung development have increased survival rates in premature infants, but survivors are often faced with a myriad of chronic illnesses such as chronic lung disease (bronchopulmonary dysplasia), retinopathy of prematurity, cerebral palsy, or developmental delay. This increased survival has resulted in a significant increase in chronic illness relative to acute illness as a cause of hospitalization and mortality (Kelly, 2010). In recent years advances in biomedicine have created a trend toward earlier diagnosis and treatment of

8   U N I T 1   Introduction to Maternity and Pediatric Nursing

A

B

FIGURE 1.1 Today fathers and partners are welcome to take an active role in the pregnancy and childbirth experience. (A) A couple can participate together in childbirth education classes. (Photo by Gus Freedman.) (B) Fathers and partners can assist the woman throughout her labor and delivery. (Photo by Joe Mitchell.)

disorders and diseases. Additionally, genetics have been linked with pathophysiologic processes. For example, female fetuses diagnosed with congenital adrenal hyperplasia, a genetic disorder resulting in a steroid enzyme deficiency leading to disfiguring anatomic abnormalities of sexual characteristics, are able to receive treatment before birth (Mayo Foundation for Medical Education and Research, 2011). In addition, early genetic defect identification allows for appropriate counseling. In addition to improvement in technology and biomedicine, a number of national and international organizations have been formed in recent years to protect children’s rights both in the United States and worldwide. These organizations focus on such issues as violence and abuse, child labor and soldiering, juvenile justice, child immigrants and orphaned children, and abandoned or homeless children— all of which have a negative impact on children’s health. A child whose rights are restored and upheld has an improved opportunity for growth, development, education, and health. The gains in child health have been huge but, unfortunately, these gains are not shared equally among all children. Certain health concerns such as asthma, obesity, poor nutrition, environmental toxin exposure, and learning or behavioral disorders affect poor children at higher rates than affluent and middle-class children (National Center for Children in Poverty [NCCP], 2011). Unintentional injuries continue to be the leading cause of death in children greater than 1  year, but children’s health remains threatened by illnesses and other healthrelated conditions in the 21st century (Centers for Disease Control and Prevention [CDC], 2012a).

Evolution of Maternal and Newborn Nursing The history of maternity nursing is characterized by innovations that became common practice in later years.

These innovations include fetal monitoring, mother/baby care, and early postpartum discharge. The driving forces behind changes in care within the social context of the times were scientific/medical developments and families’ desires for the best possible childbearing experience. Prior to World War II, American women moved from home to the hospital for childbirth in part because they were convinced that setting would improve birth outcomes. Hospitals were the major employers of maternity nurses. Early ambulation and rooming-in induced changes in the focus of care for the growing numbers of mothers and infants. Maternity nurse’s focus shifted away from carrying out tasks and performing procedures to teaching mothers about self and infant care. Improved staffing patterns in hospitals and longer hospital stays for the mothers allowed maternity nurses to spend more time with mothers for teaching purposes. Maternity nursing has changed dramatically since the Baby Boom era. The natural childbirth movement became a catalyst to bring about a change in nursing practice on the postpartum nursing units. Other innovations that came later included breastfeeding and rooming-in to facilitate maternal–newborn bonding. Maternity nurses were then able to help the new mothers learn better how to care for their infants, to promote breastfeeding and bonding. The mid-1960s and early 1970s ushered in a consumer revolt which brought back home births, prepared childbirth, the father’s involvement in the birthing process, and nurse midwives— which had all but disappeared from the American health system (Thomas, 2011). Maternal–infant bonding became recognized as an essential part of postnatal care, and maternity nurses took a lead role to facilitate it. With innovations becoming commonplace, maternity nursing practice has become more complex. How maternity nurses approach present-day challenges of increasing technology of birth, looming threats of litigation,



C h a p t e r 1   Perspectives on Maternal and Child Health Care    9 BOX 1.1

CHILDBIRTH IN AMERICA: A TIME LINE 1700s

Men did not attend births because it was considered indecent. Women faced birth not with joy and ecstasy but with fear of death. Female midwives attended the majority of all births at home.

1800s

There is a shift from using midwives to doctors among middle-class women. The word obstetrician was formed from the Latin, meaning “to stand before.” Puerperal (childbed) fever was occurring in epidemic proportions. Louis Pasteur demonstrated that streptococci were the major cause of puerperal fever that was killing ­mothers after delivery. The first cesarean section was performed in Boston in 1894. The x-ray was developed in 1895 and was used to assess pelvic size for birthing purposes.

1900s

Twilight sleep (a heavy dose of narcotics and amnesiacs) was used on women during childbirth in the United States. The United States was 17th out of 20 nations in infant mortality rates. Of all women, 50–75% gave birth in hospitals by 1940. Nurseries were started because mothers could not care for their baby for several days after receiving c­ hloroform gas. Dr. Grantley Dick–Reed (1933) wrote Childbirth Without Fear, which reduced the “fear–tension–pain” cycle women experienced during labor and birth. Dr. Fernand Lamaze (1984) wrote Painless Childbirth: The Lamaze Method, which advocated distraction and relaxation techniques to minimize the perception of pain. Amniocentesis was first performed to assess fetal growth in 1966. In the 1970s the cesarean section rate was about 5%. In 2011 it rose to 32%, where it stands currently. The 1970s and 1980s see a growing trend to return birthing back to the basics—nonmedicated, nonintervening childbirth. In the late 1900s, freestanding birthing centers—LDRPs—were designed, and the number of home births ­began to increase.

2000s

One in four women undergo a surgical birth (cesarean). CNMs once again assist couples at home, in hospitals, or in freestanding facilities with natural childbirths. Research shows that midwives are the safest birth attendants for most women, with lower infant mortality and maternal rates, and fewer invasive interventions such as episiotomies and cesareans. Childbirth classes of every flavor abound in most communities. According to the latest available data, the United States ranks 50th in the world in maternal deaths. The ­maternal mortality ratio is approximately 13 in 1,000 live births. According to the latest available data, the United States ranks 41st in the world in infant mortality rates. The infant mortality rate is approximately 6.7 in 1,000 live births.

Sources: Osterman, M. J. K., Martin, J. A., Matthews, M. S., & Hamilton, B. E. (2011). Expanded data from new birth certificates. National Vital Statistics Reports, 59(7), 1–29; Heisler, E. J. (2012). The U.S. infant mortality rate: International comparisons, underlying factors, and federal ­programs. Congressional Research Service. Retrieved from http://www.fas.org/blog/secrecy/2012/04/infant_mortality.html; Johantgen, M., F­ ountain, L., Zangaro, G., Newhouse, R., Stanik-Hutt, J., & White, K. (2012). Comparison of labor and delivery care provided by nurse-midwives and ­physicians: A systematic review, 1990 to 2008. Women’s Health Issues, 22(1), e73–e81.

and providing care under time and economic restraints is continuing to evolve. A certified nurse midwife (CNM) has postgraduate training in the care of normal pregnancy and delivery and is certified by the American College of Nurse Midwives (ACNM). A doula is a birth assistant who provides emotional, physical, and educational support to the woman and family during childbirth and the postpartum period. Many nurses working in labor and birth areas

today are credentialed in their specialty so that they can provide optimal care to the woman and her newborn.

Evolution of Pediatric Nursing In 1870, the first pediatric professorship for a physician was awarded in the United States to Abraham Jacobi, known as the father of pediatrics. For the first time, the medical community realized the need to provide

10   U N I T 1   Introduction to Maternity and Pediatric Nursing

specialized training and education about children to health care providers. In the early 1900s, Lillian Wald established the Henry Street Settlement House in New York City; this was the start of public health nursing. This facility provided medical and other services to poor families. These services included home nurse visits to teach mothers about health care. Nursing in public schools began in 1902 with the appointment of Lina Rogers as a full-time public school nurse in New York. A professional course in pediatric nursing was started in the early 1900s at Teachers’ College of Columbia University. In the 1960s, changes in the health care delivery system and shifts in the population’s health status led to the development of the nurse practitioner role. The 1970s brought cost-control systems from the federal government because of rapid escalation of health care expenditures. In addition, the considerable changes in the U.S. health care system in the 1980s have affected pediatric nursing and child health care. The emphasis of care was on quality outcomes and cost containment. Some of these changes brought more advanced practice nurses into the field of pediatrics. Finally, in the 1980s, the Division of Maternal–Child Health Nursing Practice of the American Nurses Association developed maternal–child health standards to provide important guidelines for delivering nursing care.

HEALTH STATUS OF WOMEN AND CHILDREN At one time, health was defined simply as the absence of disease. Health was measured by monitoring the mortality and morbidity of a group. Over the past century, however, the focus on health has shifted to disease prevention, health promotion, and wellness. The World Health Organization (WHO) (2012d) defines health as “a state of complete physical, mental, and social well-being, and not merely the absence of disease or infirmity.” The definition of health is complex. It is not merely the absence of disease or an analysis of mortality and morbidity statistics. In 1979, the U.S. Surgeon General’s Report, Healthy People, presented an agenda for the nation that identified the most significant preventable threats to health. With the series of updates that followed, including the present one, Healthy People 2020: The Road Ahead, the United States has a comprehensive health promotion and disease prevention agenda that is working toward improving the quantity and quality of life for all Americans (U.S. Department of Health and Human Services [USDHHS], 2012a). Overarching goals are to eliminate preventable disease, disability, injury, and premature death; achieve health equity, eliminate disparities, and improve the health of all groups; create physical and social

environments that promote good health; and p ­ romote healthy development and behaviors across every stage of life (USDHHS, 2012a). The principle behind this report is that setting national objectives and monitoring their progress can motivate action and change. In developing the health objectives, the report incorporates input from public health and prevention experts; federal, state, and local governments; over 2,000 organizations; and the public. There are specific health topic areas, including women and children’s health topics, which serve as a method for evaluation of progress made in public health. These topic areas also serve as focal points to coordinate the national health improvement efforts. For example, one objective under the physical activity topic is to increase the proportion of adolescents who meet current federal physical activity guidelines for aerobic physical activity and for muscle-strengthening activity (USDHHS, 2012a). Healthy People 2020 monitors four foundation health measures to assess the progress toward promoting health, preventing disease and disability, eliminating disparities, and improving quality of life (USDHHS, 2012a). (See the Healthy People 2020 feature for additional information on these health measures.) Measuring health status is not always a simple process. For example, some women and children with chronic illnesses do not see themselves as “ill” if their disease is under control. A traditional method of measuring health is to examine mortality and morbidity data. This information is collected and analyzed to provide an objective description of the nation’s health.

Mortality Mortality is the incidence or number of people who have died over a specific period. This statistic is presented as rates per 100,000 and is calculated from a sample of death certificates. The National Center for Health Statistics, under the DHHS, collects, analyzes, and disseminates the data on America’s mortality rates.

Maternal Mortality The maternal mortality ratio is the annual number of deaths from any cause related to or aggravated by pregnancy or its management (excluding accidental or incidental causes) during pregnancy and childbirth or within 42 days of termination of pregnancy, irrespective of the duration and site of the pregnancy, per 100,000 live births, for a specified year. In the United States, the maternal mortality ratio is mixed depending on ethnic background. African American women suffer maternal mortality ratios far higher than any other ethnic group. About 28.4 of 100,000 African American mothers die due to childbirth, as compared to much lower rates in Whites (10.5) and Hispanics (8.9)



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HEALTHY PEOPL E 2020 Four Foundation Health Measures 1.  General Health Status • Measures include: • Life expectancy • Healthy life expectancy • Years of potential life lost • Physically and mentally unhealthy days • Self-assessed health status • Limitation of activity • Chronic disease prevalence 2.  Health-Related Quality of Life and Well-Being • Measures include: • Physical, mental, and social health-related ­quality of life • Well-being/satisfaction • Participation in common activities 3. Determinants of Health (a range of personal, social, economic, and environmental factors that influence health status) • Include: • Biology • Genetics • Individual behavior • Access to health services • The environment in which people are born, live, learn, play, work, and age 4. Disparities • Measures include differences in health status based on: • Race/ethnicity • Gender • Physical and mental ability • Geography U.S. Department of Health & Human Services, 2010a.

(U.S. Department of Health and Human Services, Health Resources and Services Administration, Maternal and Child Health Bureau, 2011). The federal government has pledged to improve maternal–child care outcomes and thus reduce mortality ratios for women and children by endorsing the Healthy People 2020, but the World Health Organization (2011b) data show that the United States ranks 50th in the world for maternal mortality. In fact, maternal mortality ratios are higher than almost all ­European countries, as well as several countries in Asia and the Middle East. For a country that spends more than any other country on health care and more on childbirth-related care than any other area of hospitalization, US$86 billion a year, this is a shockingly poor return on investment (Coeytaux, Bingham, & Strauss, 2011). During the past several decades, mortality and morbidity have dramatically decreased as a result of an

increased emphasis on hygiene, good nutrition, exercise, and prenatal care for all women. However, women are still experiencing complications at significant rates. The United States is one of the most medically and technologically advanced nations and has the highest per capita spending on health care in the world, but our current mortality rates indicate the need for improvement. For example: • Two or three women die in the United States every day from pregnancy complications, and more than 30% of pregnant women (1.8  million women annually) experience some type of illness or injury during childbirth (CDC, 2011a). • The United States ranks 50th (in other words, below 49 other countries) in rates of maternal deaths (deaths per 100,000 live births (WHO, 2012b). • Most pregnancy-related complications are preventable. The leading causes of pregnancy-related mortality are hemorrhage, infection, preeclampsia-eclampsia, obstructed labor, and unsafe abortion (CDC, 2011a). The maternal mortality and morbidity rates for ­ frican American women have been three to four times A higher than for Whites (USDHHS, 2011). This major racial disparity has persisted for more than 60  years. ­ Black women have at least double the risk of pregnancy-­ related death compared with White women. This striking difference in the pregnancy-related mortality ratio is the largest disparity in the area of maternal and child health. Researchers do not entirely understand what accounts for this disparity, but some suspected causes of the higher maternal mortality rates for minority women include low socioeconomic status, limited or no insurance coverage, bias among health care providers (which may foster distrust), and quality of care available in the community. Language and legal barriers may also explain why some immigrant women do not receive good prenatal care. Lack of care during pregnancy is a major factor contributing to a poor outcome. Prenatal care is well known to prevent complications of pregnancy and to support the birth of healthy infants, but not all women receive the same quality and quantity of health care during a pregnancy. Pregnancy-related mortality is on the rise in the United States. The Healthy People 2020 goal for maternal deaths is 11.4 per 100,000 live births (USDHHS, 2011). Black women had higher degrees of hypertension and lower hemoglobin levels on admission and had presented for prenatal care much later, on ­average, than White women or not at all (Rowland, & Silver, 2011). The CDC (2011b) has noted that the disparity in maternal mortality rates between women of color and white women represent one of the largest racial disparities among public health indicators. Eliminating racial and ethnic disparities in maternal–child health care requires enhanced efforts at preventing disease, promoting

12   U N I T 1   Introduction to Maternity and Pediatric Nursing

health, and delivering appropriate and timely care. The CDC has called for more research and monitoring to understand and address racial disparities, along with increased funding for prenatal and postpartum care. Research is needed to identify causes and to design initiatives to reduce these disparities, and the CDC is calling on Congress to expand programs to provide preconception and prenatal care to underserved women.

Fetal Mortality The fetal mortality rate or fetal death rate refers to the intrauterine death of a fetus who is 20 weeks of gestation or more per 1,000 live births. Fetal mortality may be attributable to maternal factors (e.g., malnutrition, disease, or preterm cervical dilation) or fetal factors (e.g., chromosomal abnormalities or poor placental attachment). Fetal mortality is a major, but often overlooked, public health problem. Fetal mortality refers to spontaneous intrauterine death at any time during pregnancy. Fetal deaths later in pregnancy are sometimes referred to as stillbirths. The U.S. fetal mortality rate is 6.2 per 1,000 live births (NCHS, 2011a). Healthy People 2020’s goal is to reduce it to 5.6 fetal deaths (USDHHS, 2011). Much of the public concern regarding reproductive loss has concentrated on infant mortality, as less is known about fetal mortality. However, the impact of fetal mortality on U.S. families is considerable, as it provides an overall picture of the quality of maternal health and prenatal care.

The infant mortality rate is the number of deaths occurring in the first 12  months of life. It also is documented as the number of deaths of infants younger than 1 year of age per 1,000 live births. Neonatal mortality and postneonatal mortality (covering the remaining 11  months of the first year of life) are reflected in the infant mortality rate. The infant mortality rate is used as an index of the general health of a country. Generally, this statistic is one of the most significant measures of children’s health. In 2010, the infant mortality rate in the United States was 6.14 for White infants and 11.61 for Black infants per 1,000 live births (MCHB, 2012; Murphy, Xu, & Kochanek, 2012) (Fig. 1.2). Healthy People 2020’s goal is to reduce it to 6.0 (USDHHS, 2011). The infant mortality rate varies greatly from state to state as well as between ethnic groups. The United States has one of the highest gross national products in the world and is known for its technological capabilities, but its infant mortality rate is much higher, in some cases double, than most other developed nations (MCHB, 2012). In 2011, the United States ranked 41st in infant mortality rates among industrialized nations (Murphy, Xu, & Kochanek, 2012). The main causes of early infant death in the United States include problems occurring at birth or shortly thereafter, such as prematurity, low birthweight, congenital and chromosomal anomalies, sudden infant death syndrome, respiratory distress syndrome, unintentional injuries, bacterial sepsis, and necrotizing ­enterocolitis (Mathews & MacDorman 2011; Murphy et al., 2012).

Neonatal and Infant Mortality 50 Deaths per 1,000 live births

The neonatal mortality rate is the number of infant deaths occurring in the first 28 days of life per 1,000 live births. The United States now ranks 41st in the world in terms of neonatal mortality, the death rate of infants less than 1  month old. The neonatal mortality rate is 4.5 (CDC, 2012b). Healthy People 2020’s goal is to reduce it to 4.1 (USDHHS, 2011). Each year the deaths of 2 ­million babies are linked to complications during birth or within the first month. Furthermore, the burden is inequitably carried by the poor. Evidence-based strategies are urgently needed to reduce the burden of intrapartum-related deaths (Mathews & MacDorman, 2011). The reliability of the neonatal mortality estimates depends on accuracy and completeness of reporting and recording of births and deaths. Underreporting and misclassification are common, especially for deaths occurring early on in life. Perinatal mortality, defined as the number of stillbirths and deaths in the first week of life per 1,000 live births, is also a useful indicator. The perinatal mortality is the sum of the fetal mortality and the neonatal mortality. Work is ongoing to improve estimates of stillbirth rates, a major component of perinatal mortality (WHPO, 2012e).

40 Infant

30

20 Neonatal 10 0 1940

1950

1960

1670

1980

1990

2000 2007

NOTE: Rates are infant (under 1 year), neonatal (under 28 days), and postneonatal (28 days–11 months) deaths per 1,000 live births in specified group. SOURCE: CDC/NCHS, National Vital Statistics System, Mortality

FIGURE 1.2 Infant and neonatal mortality from 1940 to 2007. Adapted from Xu, J. Q., Kochanek, K. D., Murphy, S. L., & Tejada-Vera, B. (2010). Deaths: Final Data 2007. National Vital Statistics Reports, 58(19). Hyattsville, MD: National Center for Health Statistics Retrieved on January 30, 2012, at http://www.cdc.gov/nchs/data/nvsr/nvsr58/ nvsr58_19.pdf



C h a p t e r 1   Perspectives on Maternal and Child Health Care    13

Take Note! Non-Hispanic, African American infants have consistently had higher infant mortality rates than other ethnic groups (Murphy et al., 2012). Congenital anomalies remain the leading cause of infant mortality in the United States (Murphy et al., 2012). In addition, low birthweight and prematurity are major indicators of infant health and significant predictors of infant mortality (Kelly, 2010). The lower the birthweight, the higher the risk of infant mortality. The percentage of infants born preterm in the United States is increasing, thus the impact of preterm-related causes of infant death has increased. Therefore, the high incidence of low birthweight ( 3 months • Thyroid replacement drugs • Smoking and consuming alcohol • Low calcium and vitamin D intake • Excessive amounts of caffeine • Personal history of nontraumatic fracture • Anorexia nervosa or bulimia (NOF, 2011a) Currently, no method exists for directly measuring bone mass. Instead a bone mineral density (BMD) measurement is used. BMD is a two-dimensional measurement of the average content of mineral in a section of bone. BMD evaluations are made at the hip, femoral neck, and spine. There is a significant relationship between BMD and fracture: as BMD is reduced, the risk of fracture increases (Tufts, 2011). Screening tests to measure bone density are not good predictors for young women who might be at risk for developing this condition. Dualenergy x-ray absorptiometry (DXA or DEXA) is a screening test that calculates the mineral content of the bone at the spine and hip. It is highly accurate, fast, and relatively inexpensive. The dual energy x-ray absorptiometry scan (DEXA scan) is the gold standard radiologic method for identifying osteoporosis through measuring BMD (U.S. Preventive Services Task Force, 2011). The WHO Working Group on Osteoporosis has recently developed an online tool, FRAX, to assess hip fracture probability based on several individual client



and clinical factors. The FRAX tool serves to project fracture risk through statistical models that integrate individual clinical risk factors, such as physical characteristics, ethnicity, or medical history, as well as bone density. It is now recommended that assessment of fracture risk, using both clinical risk factors and BMD, be done before initiating treatment, not relying solely on BMD as the threshold (Tufts, 2011). Hip fracture is the most devastating of the fragility fractures secondary to osteoporosis. A number of medical, social, and economic consequences follow a hip fracture. Of women older than 50  years, on average, 24% die within the first year after hip fracture (Roy, Heckman & O’Connor, 2011). The concern surrounding osteoporosis is not the rate of fracture alone but also the potential for lifelong disability secondary to fracture. The incidence of hip fracture is estimated to double by the year  2025 and nearly double again by 2050. For women, this is a projected 240% increase (NOF, 2011a). The best management for this painful, crippling, and potentially fatal disease is prevention. Women can modify many risk factors by doing the following: • Engage in daily weight-bearing exercise, such as walking to increase osteoblast activity. • Increase calcium and vitamin D intake. • Avoid smoking and excessive alcohol (more than two drinks per day). • Discuss bone health with a health care provider. • When appropriate, have a bone density test and take medication if needed (NOF, 2011a). Medications that can help in preventing and managing osteoporosis include: • HT (Premarin) • SERMs (raloxifene [Evista]) • Calcium and vitamin D supplements (Tums) • Bisphosphonates (Actonel, Fosamax, Boniva, or Reclast) • Parathyroid hormone (Forteo) • Calcitonin (Miacalcin) (King & Brucker, 2011)

Preventing and Managing Cardiovascular Disease Cardiovascular disease (CVD) remains the number-one killer of women in the United States (DeVon, 2011). More women die from heart disease and stroke than the next five causes of death combined, including breast cancer. Half a million women die annually in the United States of cardiovascular disease, with strokes accounting for about 20% of the deaths (Alexander et al., 2010). This translates into approximately one death every minute. While men’s CVD mortality has decreased since the 1980s, women’s CVD mortality has climbed. This has resulted in a sexrelated CVD mortality gap, with women having higher mortality than men since 1984. Contributing to this

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female-majority CVD mortality gap is a lack of awareness of CVD risk among women and their physicians. Awareness campaigns, such as the Heart Truth and the Red Dress symbol, appear to have improved recognition of CVD risk in women. Further, female-specific guidelines have been developed to prevent and reduce CVD in women. Though the current understanding of the role of menopause in CVD is controversial, studies suggest that menopause does not exacerbate CVD independent of aging, and hormone replacement therapy is not effective for secondary prevention of CVD ( Johannes & Bairey Merz, 2011). For the first half of a woman’s life, estrogen seems to be a protective substance for the cardiovascular system by smoothing, relaxing, and dilating blood vessels. It even helps boost HDL and lower low-density lipoprotein levels, helping to keep the arteries clean from plaque accumulation. But when estrogen levels plummet as women age and experience menopause, the incidence of CVD increases dramatically. Menopause is not the only factor that increases a woman’s risk for CVD. Lifestyle and medical history factors such as the following play a major role: • Smoking • Obesity • High-fat diet • Sedentary lifestyle • High cholesterol levels • Family history of cardiovascular disease • Hypertension • Apple-shaped body • Diabetes Two of the major risk factors for coronary heart disease are hypertension and dyslipidemia. Both are modifiable and can be prevented by lifestyle changes and, if needed, controlled by medication. This is why prevention is essential. In addition, women who experience early menopause lose the protection afforded by endogenous estrogen to the cardiac system and are at greater risk for more extensive atherosclerosis. Major preventive strategies include a healthy diet, increased activity, exercise, smoking cessation, decreased alcohol intake, and weight reduction. Nurses, particularly those caring for women during their reproductive years, are uniquely positioned to provide education and support for women’s long-term cardiovascular health. Raising awareness of heart disease in women is an essential role for nurses. The good news is that CVD is largely preventable. Because CVD is a chronic disease that develops over time, primary prevention lifestyle modification interventions are most effective if initiated before the development of overt disease. Stressing the importance of lifestyle modifications must begin early in life and should be reinforced from the beginning of a young woman’s reproductive years through menopause. Nurses are in an ideal position to teach the

156   U N I T 2   Women’s Health Throughout the Life Span

importance of good nutrition, healthy weight, and daily exercise before CVD becomes clinically evident.

Nursing Assessment Menopausal transition is a universal and irreversible part of the overall aging process involving a woman’s reproductive system. Although not a disease state, menopausal transition does place women at greater risk for the development of many conditions of aging. Nurses can help the woman become aware of her risk for postmenopausal diseases, as well as strategies to prevent them. The nurse can be instrumental in assessing risk factors and planning interventions in collaboration with the client. These might include: • Screening for osteoporosis, cardiovascular disease, and cancer risk: • Assessment of blood pressure to identify hypertension • Blood cholesterol test to identify hyperlipidemia risk • Mammogram to find a cancerous lesion • Pap smear to identify cervical cancer • Pelvic examination to identify endometrial cancer or masses • Digital rectal examination to assess for colon cancer • Bone density testing as a baseline at menopause to identify osteopenia (low bone mass), which might lead to osteoporosis • Assessing lifestyle to plan strategies to prevent chronic conditions: • Dietary intake of fat, cholesterol, and sodium • Weight management • Calcium intake • Use of tobacco, alcohol, and caffeine • Amount and type of daily exercise routines

Nursing Management There is no “magic bullet” in managing menopause. Nurses can counsel women about their risks and help them to prevent disease and debilitating conditions with specific health maintenance education. Women should make their own decisions, but the nurse should make sure they are armed with the facts to do so intelligently. Nurses can offer a thorough explanation of the menopausal process, including the latest research findings, to help women understand and make decisions about this inevitable event. If the woman decides to use HT to control her menopausal symptoms, after being thoroughly educated, she will need frequent reassessment. There are no hardand-fast rules that apply to meeting a woman’s individual needs. The nurse can provide realistic expectations of the therapy to reduce the woman’s anxiety and concern. It is also useful to emphasize the value of friends to gain support and share information and resources. Often just talking about emotional difficulties such as

the death of a parent or problematic relationships helps solve problems. It also shows the woman that her emotional responses are valid. Healthy lifestyles and stress management techniques are vital to health and longevity, and it is important to keep these on the client’s agenda when discussing menopause (Boston Women’s Health Book Collective, 2011). Evidence-based interventions include lifestyle modifications, risk management therapies, and preventive drug interventions, such as the following: • Participate actively in maintaining health. • Exercise regularly to prevent CVD and osteoporosis. • Take supplemental calcium and eat appropriately to prevent osteoporosis. • Stop smoking to prevent lung and heart disease. • Reduce caffeine and alcohol intake to prevent osteoporosis. • Monitor blood pressure, lipids, and diabetes (drug therapy management). • Use low-dose aspirin to prevent blood clots. • Reduce dietary intake of fat, cholesterol, and sodium to prevent cardiovascular disease. • Maintain a healthy weight for body frame. • Perform breast self-examinations for breast awareness. • Control stress to prevent depression (DeVon, 2011). These life approaches may seem low tech, but they can stave off menopause-related complications such as cardiovascular disease, osteoporosis, and depression. These tips for healthy living work well, but the client needs to be motivated to stick with them.

KEY CONCEPTS Establishing good health habits and avoiding risky behaviors early in life will prevent chronic conditions later in life. Premenstrual syndrome has more than 200 symptoms, and at least two different syndromes have been recognized: PMS and premenstrual dysphoric disorder (PMDD). Endometriosis is a condition in which bits of functioning endometrial tissue are located outside their normal site, the uterine cavity. Infertility is a widespread problem that has an emotional, social, and economic impact on c­ ouples. More than half of all unintended pregnancies occur in women who report using some method of birth control during the month of conception. Hormonal methods include oral contraceptives, injectables, implants, vaginal rings, and transdermal patches.



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Recent studies have shown that the extension of active extended cycle oral contraceptive pills carries the same safety profile as the conventional 28-day regimens (Hatcher et al., 2012). Currently two IUCs available in the United States: the copper ParaGard-TCu-380A and the levonorgestrel intrauterine system (LNG-IUS) called Mirena, a levonorgestrel-releasing device (King & Brucker, 2011). Oral contraceptives, sterilization, and male condoms are the most popular methods of contraception in the United States and worldwide (Hatcher et al., 2012). Menopause, with a dramatic decline in estrogen levels, affects not only the reproductive organs but also other body systems. Most women with osteoporosis do not know they have the disease until they sustain a fracture, usually of the wrist or hip (NOF, 2011a). Half a million women die annually in the United States of cardiovascular diseases, with strokes accounting for about 20% of the deaths (Alexander et al., 2010). Nurses should aim to have a holistic approach to the sexual health of women from menarche through menopause.

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158   U N I T 2   Women’s Health Throughout the Life Span Hansen, H. (2011, November). Increasing use of infertility treatment raises concerns about human fertility. Fertility Weekly, pp. 3–4. Harlow, S., & Paramsothy, P. (2011). Menstruation and the menopausal transition. Obstetrics and Gynecology Clinics of North America, 38(3), 595–607. Hatcher, R. A., et al. (2012). Contraceptive technology (20th ed.). New York, NY: Ardent Media. Holder, A. (2011). Dysmenorrhea. eMedicine. Retrieved from http:// emedicine.medscape.com/article/795677-overview Holland-Hall, C. (2011). Sterilization: An option for all women. Journal of Child Neurology, 26(5), 651–653. Holloway, D. (2011). An overview of the menopause: Assessment and management. Nursing Standard, 25(30), 47–58. Htay, T. T. (2011). Premenstrual dysphoric disorder. eMedicine. Retrieved from http://emedicine.medscape.com/article/293257-overview Hwang, K., Walters, R., & Lipshultz, L. (2011). Contemporary concepts in the evaluation and management of male infertility. Nature Reviews: Urology, 8(2), 86–94. Ian, F. (2011). The FIGO recommendations on terminologies and definitions for normal and abnormal uterine bleeding. Seminars in Reproductive Medicine, 29(5), 383–390. Jassim, G. A. (2011). Strategies for managing hot flashes. Journal of Family Practice, 60(6), 333–339. Jennings, V., Sinai, I., Sacieta, L., & Lundgren, R. (2011). Two Day Method: A quick-start approach. Contraception, 84(2), 144–149. Jensen, J. R., Morbeck, D. E., & Coddington C. C., III. (2011). Fertility preservation. Mayo Clinic Proceedings, 86(1), 45–49. Johannes, J., & Bairey Merz, C. (2011). Is cardiovascular disease in women inevitable?: Preparing for menopause and beyond. Cardiology in Review, 19(2), 76–80. Kapoor, D. W. (2011). Endometriosis. eMedicine. Retrieved from http:// emedicine.medscape.com/article/271899-overview Kass-Wolff, J. H., & Fisher, J. E. (2011). Menopause and the hormone controversy: Clarification or confusion? Nurse Practitioner, 36(7), 22–30. Kerns, J., & Darney, P. (2011). Vaginal ring contraception. Contraception, 83(2), 107–115. Kessenich, C. R. (2011). Inevitable menopause. Nursing Spectrum. Retrieved from http://ce.nurse.com/ce232-60/Inevitable-Meno​ pause King, T. L., & Brucker, M. C. (2011). Pharmacology for women’s health. Sudbury, MA: Jones & Bartlett. Koninckx, P., & Brosens, I. (2011). Dietary fat consumption and endometriosis risk. Human Reproduction, 26(3), 731–732. Krantz, C. (2012a). Amenorrhea. In E. T. Bope & R. D. Kellerman (Eds.), Conn’s current therapy 2012 (pp. 983-985). Philadelphia, PA: Elsevier Health. Krantz, C. (2012b). Menstrual cycle. In E. T. Bope & R. D. Kellerman (Eds.), Conn’s current therapy 2012 (pp. 983-984). Philadelphia, PA: Elsevier Health. Kubba, A. (2011). Implanon: Let’s not over-react. Prescriber, 22(4), 7–8. Kuyoh, M. A., Toroitich-Ruto, C., Grimes, D. A., Schulz, K. F., Gallo, M. F., & Lopez, L. M. (2011). Sponge versus diaphragm for contraception. Cochrane Database of Systematic Reviews, 2011(3). doi:10.1002/14651858.CD003172 Ledger, B. (2011). Nurses’ support is crucial during fertility treatments. Nursing Standard, 25(33), 32–33. Maguire, K., & Westhoff, C. (2011). The state of hormonal contraception today: Established and emerging noncontraceptive health benefits. American Journal of Obstetrics and Gynecology, 205(4 Suppl), S4–S8. Mantell, J. E., West, B. S., Sue, K., Hoffman, S., Exner, T. M., Kelvin, E., & Stein, Z. A. (2011).Health care providers: A missing link in understanding acceptability of the female condom. AIDS Education & Prevention, 23(1), 65–77. Miller, L. M. (2011). College student knowledge and attitudes toward emergency contraception. Contraception, 83(1), 68–73. Missmer, S., Seifer, D., & Jain, T. (2011). Cultural factors contributing to health care disparities among patients with infertility in midwestern United States. Fertility and Sterility, 95(6), 1943–1949. Montazeri, S. (2011). Non-pharmacological treatment of premenstrual syndrome. African Journal of Midwifery & Women’s Health, 5(3), 148–152.

Morreale, M., Balon, R., Tancer, M., & Diamond, M. (2011). The impact of stress and psychosocial interventions on assisted reproductive technology outcome. Journal of Sex & Marital Therapy, 37(1), 56–69. Munro, M., Dickersin, K., Clark, M., Langenberg, P., Scherer, R., & Frick, K. (2011). The surgical treatments outcomes project for dysfunctional uterine bleeding: Summary of an Agency for Health Research and Quality-sponsored randomized trial of endometrial ablation versus hysterectomy for women with heavy menstrual bleeding. Menopause, 18(4), 445–452. National Institute of Child Health and Human Development [NICHD]. (2011). Endometriosis (NIH Pub. No. 02-2413). Retrieved from http:// www.nichd.nih.gov/publications/pubs/endometriosis National Osteoporosis Foundation [NOF]. (2011a). Osteoporosis: Fast facts. Retrieved from http://www.nof.org/osteoporosis/diseasefacts.htm National Osteoporosis Foundation [NOF]. (2011b). Steps to prevent osteoporosis. Retrieved from http://www.nof.org/prevention/index.htm North American Menopause Society. (2011). Recommendations for estrogen and progesterone use in post-menopausal women. Menopause, 15(4), 584–603. Occupational Health and Safety Administration. (2011). Latex allergy. Retrieved from http://www.osha.gov/SLTC/latexallergy Oral, E., & Aydogan, B. (2011). Primary amenorrhea. Turkish Pediatric Archive, 46, 92–96. O’Reilly, M. (2009). Careful counsel: Management of unintended pregnancy. Journal of the American Academy of Nurse Practitioners, 21(11), 596–602. Orentlicher, D. (2011). The legislative process is not fit for the abortion debate. Hastings Center Report, 41(4), 13–14. Pagana, K. D., & Pagana, T. J. (2012). Mosby’s diagnostic and laboratory test reference (12th ed.). St. Louis, MO: Elsevier Mosby. Pavone, M., Hirshfeld-Cytron, J., & Kazer, R. (2011). The progressive simplification of the infertility evaluation. Obstetrical & Gynecological Survey, 66(1), 31–41. Payne, R., Guinn, C., & Ponder, B. (2011). Supporting the couple with conception challenges. Nurse Practitioner, 36(8), 38–45. Pinkerton, J. V. (2011a). The menstrual cycle—Mood disorder tandem: Screening, diagnosis, and treatment. OBG Management, 23(12), 24–30. Pinkerton, J. V. (2011b). Pharmacological therapy for abnormal uterine bleeding. Menopause, 18(4), 453–461. Planned Parenthood. (2011). Facts about birth control. Retrieved from http://www.plannedparenthood.org/bc/bcfacts4.html Popat, V., & Sullivan, S. D. (2011). Amenorrhea. eMedicine. Retrieved from http://emedicine.medscape.com/article/252928-overview Puscheck, E. E., & Woodward, T. L. (2011) Infertility. eMedicine. Retrieved from http://emedicine.medscape.com/article/274143-overview Ratzan, S. C. (2011). Our “new” hope for HIV prevention—Condoms. Journal of Health Communication. 16(1), 1–2. Reddish, S. (2011). Menopausal transition—Assessment in general practice. Australian Family Physician, 40(5), 266–272. RESOLVE (National Infertility Association). (2011). What is infertility? Retrieved from http://www.resolve.org/infertility-overview/ what-is-infertility Roush, K. (2011). Menopausal hormone therapy: What we know now. American Journal of Nursing, 111(6), 38–49. Roy, A., Heckman, M., & O’Connor, M. (2011). Optimizing screening for osteoporosis in patients with fragility hip fracture. Clinical Orthopedics & Related Research, 469(7), 1925–1930. Samra-Latif, O. M., & Wood, E. (2011). Contraception. eMedicine. Retrieved from http://emedicine.medscape.com/article/258507-overview Santoro, N. F., & Neal-Perry, G. (2010). Amenorrhea: A case-based clinical guide. New York, NY: Springer. Saul, T., & Dave, A. K. (2011). Emergent treatment of endometriosis. eMedicine. Retrieved from http://emedicine.medscape.com/ article/795771-overview Schnatz, P. (2011). The 2010 North American Menopause Society position statement: Updates on screening, prevention and management of postmenopausal osteoporosis. Connecticut Medicine, 75(8), 485–487. Schuiling, K.D. & Likis, F.E. (2013) Women’s gynecologic health. (2nd ed.), Burlington, MA: Jones & Bartlett Learning. Schwartz, J. (2011). New data emerges on one-size diaphragm. Contraceptive Technology Update, 32(12), 139–140.

Seval, D. L., Buckley, T., Kuehl, T. J., & Sulak, P. J. (2011). Attitudes and prescribing patterns of extended-cycle oral contraceptives. Contraception, 84(1), 71–75. Shih, G., Turok, D., & Parker, W. (2011). Vasectomy: The other (better) form of sterilization. Contraception, 83(4), 310–315. Shufelt, C., Johnson, B., Berga, S., Braunstein, G., Reis, S., Bittner, V., . . . Merz, C. (2011). Timing of hormone therapy, type of menopause, and coronary disease in women: Data from the National Heart, Lung, and Blood Institute-sponsored Women’s Ischemia Syndrome Evaluation. Menopause, 18(9), 943–950. Skidmore-Roth, L. (2011). Mosby’s drug guide for nurses, with 2012 updates (9th ed.). St. Louis, MO: Elsevier Mosby. Stacey, D. (2011a). The Today sponge. Retrieved from http://contraception.about.com/od/overthecounterchoices/p/sponge.htm Stacey, D. (2011b). What is the Billings method? Retrieved from http:// contraception.about.com/od/naturalmethods/f/billings.htm Stoddard, A., McNicholas, C., & Peipert, J. F. (2011). Efficacy and safety of long-acting reversible contraception. Drugs, 71(8), 969–980. Storch, S. (2011). Secondary amenorrhea. MedlinePlus. Retrieved from http://www.nlm.nih.gov/medlineplus/ency/article/001219.htm Tavallaee, M., Joffres, M. R., Corber, S. J., Bayanzadeh, M., & Rad, M. (2011). The prevalence of menstrual pain and associated risk factors among Iranian women. Journal of Obstetrics & Gynecology Research, 37(5), 442–451. Thomas, C. (2011). Treatment options for dysfunctional uterine bleeding. Nurse Practitioner, 36(8), 14–21. Thomas, H., Bryce, C., Ness, R., & Hess, R. (2011). Dyspareunia is associated with decreased frequency of intercourse in the menopausal transition. Menopause, 18(2), 152–157.

C h a p t e r 0 4  Common Reproductive Issues   159 Thurston, R., & Joffe, H. (2011). Vasomotor symptoms and menopause: Findings from the study of Women’s Health across the Nation. Obstetrics & Gynecology Clinics of North America, 38(3), 489–501. Tufts, G. (2011). The treatment of osteopenia in Asian women: A new approach. Journal of the American Academy of Nurse Practitioners, 23(8), 434–442. UNFPA. (2011). The state of the world population 2011 report. Retrieved from http://foweb.unfpa.org/SWP2011/reports/EN-SWOP2011-­FINAL. pdf Unuane, D., Tournaye, H., Velkeniers, B., & Poppe, K. (2011). Endocrine disorders & female infertility. Best Practice & Research. Clinical Endocrinology & Metabolism, 25(6), 861–873. U.S. Food and Drug Administration [FDA]. (2009). FDA approves over-the-counter access to generic Plan B and for women 18 and older; prescription remains required for those 17 and younger. FDA News. Retrieved from http://www.fda.gov/NewsEvents/Newsroom/­ PressAnnouncements/ucm168870.htm U.S. Food and Drug Administration [FDA]. (2011). Expanding contraceptive choice. Retrieved from http://www.prb.org/pdf09/­contraceptive​ choice.pdf U.S. Preventive Services Task Force. (2011). Screening for osteoporosis: Recommendation statement. American Family Physician, 83(10), 1197–1200. World Health Organization [WHO]. (2011). Infertility in developing countries. Reproductive Health. Retrieved from http://www.who.int/ reproductive-health/infertility/index.htm Zite, N., & Borrero, S. (2011). Female sterilization in the United States. European Journal of Contraception & Reproductive Health Care, 16(5), 336–340.

CHAPTER W O R K S H E E T MULTIPLE-CHOICE QUESTIONS 1. A couple is considered infertile after how many months of trying to conceive? a. 6 months b. 12 months c. 18 months d. 24 months 2. A couple reports that their condom broke while they were having sexual intercourse last night. What would you advise to prevent pregnancy? a. Inject a spermicidal agent into the woman’s vagina immediately. b. Obtain emergency contraceptives and take them immediately. c. Douche with a solution of vinegar and hot water tonight. d. Take a strong laxative now and again at bedtime. 3. Which of the following combination contraceptives has been approved for extended continuous use? a. Seasonale b. Triphasil c. Ortho Evra d. Mirena 4. Which of the following measures helps prevent osteoporosis? a. Supplementing with iron b. Sleeping 8 hours nightly c. Eating lean meats only d. Doing weight-bearing exercises 5. Which of the following activities will increase a woman’s risk of cardiovascular disease if she is taking oral contraceptives? a. Eating a high-fiber diet b. Smoking cigarettes c. Taking daily multivitamins d. Drinking alcohol 6. The nurse is preparing to teach a class to a group of middle aged women regarding the most common vasomotor symptoms experienced during menopause and possible modalities of treatment available. Which of the following would be a vasomotor symptom experienced by menopausal women? a. Weight gain b. Bone density c. Hot flashes d. Heart disease

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7. Throughout life, a woman’s most proactive activity to promote her health would be to engage in: a. Consistent exercise b. Socialization with friends c. Quality quiet time with herself d. Consuming water 8. What comment by a woman would indicate that a diaphragm is not the best contraceptive device for her? a. “My husband says it is my job to keep from getting pregnant.” b. “I have a hard time remembering to take my vitamins daily.” c. “Hormones cause cancer and I don’t want to take them.” d. “I am not comfortable touching myself down there.” CRITICAL THINKING EXERCISE 1. Ms. London, age  25, comes to your family planning clinic requesting to have an intrauterine contraceptive (IUC) inserted because “birth control pills give you cancer.” In reviewing her history, you note she has been into the STI clinic three times in the past year with vaginal infections and was hospitalized for pelvic inflammatory disease (PID) last month. When you question her about her sexual history, she reports having sex with multiple partners and not always using protection. a. Is an IUC the most appropriate method for her? Why or why not? b. What myths/misperceptions will you address in your counseling session? c. Outline the safer sex discussion you plan to have with her. STUDY ACTIVITIES 1. Develop a teaching plan for an adolescent with premenstrual syndrome and dysmenorrhea. 2. Arrange to shadow a nurse working in family planning for the morning. What questions does the nurse ask to ascertain the kind of family planning method that is right for each woman? What teaching goes along with each method? What follow-up care is needed? Share your findings with your classmates during a clinical conference.

CHAPTER W O R K S H E E T 3. Surf the Internet and locate three resources for infertile couples to consult that provide support and resources. 4. Sterilization is the most prevalent method of contraception used by married couples in the United States. Contact a local urologist and gynecologist to learn about the procedure involved and the cost of a male and female sterilization. Which procedure poses less risk to the person and costs less? 5. Take a field trip to a local drugstore to check out the variety and costs of male and female condoms. How many different brands did you find? What was the range of costs?

6. Noncontraceptive benefits of combined oral contraceptives include which of the following? Select all that apply. a. Protection against ovarian cancer b. Protection against endometrial cancer c. Protection against breast cancer d. Reduction in incidence of ectopic pregnancy e. Prevention of functional ovarian cysts f. Reduction in deep venous thrombosis g. Reduction in the risk of colorectal cancer

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5 KEY TERMS bacterial vaginosis cervicitis chlamydia genital/vulvovaginal candidiasis gonorrhea pelvic inflammatory disease (PID) sexually transmitted infection (STI) syphilis trichomoniasis vaginitis

Sexually Transmitted Infections Learning Objectives Upon completion of the chapter, you will be able to: 1. Define the key terms used in this chapter. 2. Evaluate the spread and control of sexually transmitted infections. 3. Identify risk factors and outline appropriate client education needed in common sexually transmitted infections. 4. Describe how contraceptives can play a role in the prevention of sexually transmitted infections. 5. Analyze the physiologic and psychological aspects of sexually transmitted infections. 6. Outline the nursing management needed for women with sexually transmitted infections.

Sandy, a 19-year-old, couldn’t imagine what these “things” were that appeared “down there” in her genital area last week. She was too embarrassed to tell anyone, so she stopped by the college health service today to find out what they were.

WOW

Words of Wisdom

Unconditional self-acceptance in clients is the core to reducing risky behavior and fostering peace of mind.



C h a p t e r 0 5  Sexually Transmitted Infections   163

Sexually transmitted infections (STIs) are i­nfections of the reproductive tract caused by microorganisms transmitted through vaginal, anal, or oral sexual intercourse (Centers for Disease Control and Prevention [CDC], 2012a). STIs pose a serious threat not only to women’s sexual health but also to the general health and well-being of millions of people worldwide. STIs constitute an epidemic of tremendous magnitude. An estimated 65 million people live with an incurable STI, and another 19 million are infected each year. STIs cost the U.S. health care system $17  billion annually (CDC, 2012a), and their incidence continues to rise. STIs are biologically sexist, presenting greater risk and causing more complications among women than among men. Women are diagnosed with two thirds of the estimated 19 million new cases of STIs annually in the United States. After only a single exposure, women are twice as likely as men to acquire infections from pathogens causing gonorrhea, chlamydia infection, hepatitis B, human papillomavirus virus, and syphilis (Schuiling & Likis, 2013). STIs may contribute to cervical cancer, infertility, ectopic pregnancy, chronic pelvic pain, and death. Certain infections can be transmitted in utero to the fetus or during childbirth to the newborn (Table  5.1). STIs know no class, racial, ethnic,

TABLE 5.1

or social barriers—all individuals are vulnerable if exposed to the infectious organism. The problem of STIs has still not been tackled adequately on a global scale, and until this is done, numbers worldwide will continue to increase. A special section on STIs and adolescents is presented next, followed by discussion of specific STIs categorized according to the CDC framework. The CDC groups STIs according to the major symptom manifested (Box 5.1). A section on preventing STIs is included at the end of the chapter.

SEXUALLY TRANSMITTED INFECTIONS AND ADOLESCENTS Individuals age 15 to 25  years represent almost half of all cases of new STIs acquired (CDC, 2011c). Each year there are 4  million cases of STIs among teenagers (American Medical Association [AMA], 2012). In the United States, teens who are sexually active experience high rates of STIs, and some groups are at higher risk, including ­African American, American Indian/Alaska Native, and Hispanic youths, youths living in poverty, and those with limited educational attainment (CDC, 2011c).

EFFECTS OF SEXUALLY TRANSMITTED INFECTIONS ON THE FETUS OR NEWBORN

STI

Effects on Fetus or Newborn

Chlamydia

Newborn can be infected during delivery Eye infections (neonatal conjunctivitis), pneumonia, low birthweight, increased risk of premature rupture of the membranes (PROM), preterm birth, and stillbirth

Gonorrhea

Newborn can be infected during delivery. Increased risk of miscarriage, PROM, and p ­ reterm birth Rhinitis, vaginitis, urethritis, inflammation of sites of fetal monitoring Gonococcal ophthalmia neonatorum can lead to blindness and sepsis (including arthritis and meningitis)

Herpes type II (­ genital herpes)

Contamination can occur during birth. Newborn may develop skin or mouth sores

Syphilis

Can be passed in utero

Mental retardation, premature birth, low birthweight, blindness, death

Can result in fetal or infant death Congenital syphilis symptoms include skin ulcers, rashes, fever, weakened or hoarse cry, swollen liver and spleen, jaundice and anemia, various deformations Trichomoniasis

Low birthweight, increased risk of PROM, and preterm birth

Venereal warts

May develops warts in throat (laryngeal papillomatosis); uncommon but life-threatening

Adapted from March of Dimes. (2011). Sexually transmitted infections. Retrieved on June 12, 2012, from http://www.marchofdimes.com/ pregnancy/complications_stis.html

164   U N I T 2   Women’s Health Throughout the Life Span

adolescence and young adulthood, women’s columnar epithelial cells are especially sensitive to invasion by sexually transmitted organisms, such as chlamydia and gonococci, because they extend out over the vaginal surface of the cervix, where they are unprotected by cervical mucus; these cells recede to a more protected location as women age. Social factors such as poverty, lack of education, social inequality, and limited access to health care services impact the prevalence of STIs in this high-risk population. Adolescent females may perceive that they have limited power over when and where intercourse occurs with their partners. They typically lack negotiating skills and self-confidence needed to successfully negotiate for safer sex practices and thus are exposed to STIs (AMA, 2012). Behaviorally, adolescent and young adults tend to think they are invincible and deny the risks of their behavior. This risky behavior exposes them to STIs and HIV/AIDS. Adolescents frequently have unprotected intercourse, they engage in partnerships of limited duration, and they face many obstacles that prevent them from using the health care system (CDC, 2010a) Healthy People 2020 5-1.

BOX 5.1

CDC CLASSIFICATION OF STIs • Infections characterized by vaginal discharge • Vulvovaginal candidiasis • Trichomoniasis • Bacterial vaginosis • Infections characterized by cervicitis • Chlamydia • Gonorrhea • Infections characterized by genital ulcers • Genital herpes simplex • Syphilis • Pelvic inflammatory disease (PID) • Human immunodeficiency virus (HIV) • Human papillomavirus infection (HPV) • Vaccine-preventable STIs • Hepatitis A • Hepatitis B • Ectoparasitic infections • Pediculosis pubis • Scabies

Nursing Assessment Take Note! It is estimated that before graduating from high school, 25% of adolescents will contract an STI ­(Guttmacher Institute, 2012). Biological, social, and behavioral factors place teenagers at high risk. Female adolescents are more susceptible to STIs due to their anatomy. During

Many health care providers fail to assess adolescent sexual behavior and STI risks, to screen for asymptomatic infection during clinic visits, or to counsel adolescents on STI risk reduction. Nurses need to remember that they play a key role in the detection, prevention, and treatment of STIs in adolescents. All states allow adolescents to give consent to confidential STI testing and treatment. Table  5.2 discusses clinical manifestations of common STIs in adolescents.

HEALTHY PEOPL E 2020 Objectives

Significance

Reduce the proportion of adolescents and young adults with Chlamydia trachomatis infections. Reduce gonorrhea. Reduce sustained domestic transmission of primary and secondary syphilis. (Developmental) Reduce the proportion of females with human papillomavirus (HPV) infection. Reduce the proportion of young adults with genital herpes infection due to herpes simplex type 2 Increase the proportion of sexually active persons aged 15 to 19 years who use condoms to both ­effectively prevent pregnancy and provide barrier protection against disease.

Provide confidential care to all adolescents. Assess for sexual behaviors and STI risks during clinic visits; take every opportunity to educate on risks of STIs and risk reduction. Be direct and nonjudgmental and tailor your approach to the client. Encourage adolescents to postpone initiation of sexual intercourse for as long as possible. For teens who have already had sexual intercourse, encourage abstinence at this point. Encourage adolescents to minimize their lifetime number of sexual partners. Educate about the importance of correct and consistent condom use.

Source: U.S. Department of Health and Human Services. (2010). Healthy People 2020. [Online] Available at http:// www.healthypeople.gov/2020/topicsobjectives2020/

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Chlamydia trachomatis (bacteria)

Neisseria gonorrhoeae (bacteria)

Gonorrhea Curable STI Client often c­ o-infected with Chlamydia trachomatis

Causative Organism

Vaginal, anal, oral sex, and by childbirth

Vaginal, anal, oral sex, and by childbirth

Transmission Mode

Gram stain or culture directly for the bacterium or same noninvasive, nonculture-based test as Chlamydia Females: screened annually Male: Screen high-risk clients

Culture fluid from urethral swabs in males or endocervical swabs for females. Noninvasive, nonculturebased testing is avail able using nucleic acid application and testing from urine-single test can test for Chlamydia and gonorrhea Conjunctival secretions in neonates Females: screened annually Male: Screen high-risk clients

Diagnostic Testing and Recommended Screening for Sexually Active Adolescent

May be asymptomatic or not recognizable symptoms until serious complications such as pelvic inflammatory disease Dysuria Frequency Vaginal discharge (yellow and foul)

May be asymptomatic Dysuria, urinary frequency Vaginal discharge (mucus or pus) Endocervicitis May lead to pelvic inflammatory disease, ectopic pregnancy, infertility Can cause inflammation of the rectum and conjunctiva Can infect the throat from oral sexual contact with an infected partner

Female Symptoms

SEXUALLY TRANSMITTED INFECTIONS COMMON IN ADOLESCENTS

Chlamydia Curable STI Seen frequently among sexually active adolescents and young adults Sexually ­active a­ dolescents should be screened at least annually.

Disease

TABLE 5.2

Most produce symptoms, but can be asymptomatic Dysuria Penile discharge (pus) Arthritis

May be asymptomatic Dysuria, urethral itching Penile discharge ­(mucus or pus) Urethral tingling May lead to epididymitis and sterility Can cause inflammation of the rectum and conjunctiva Can infect the throat from oral sexual contact with an infected partner

Male Symptoms

(continued)

Usually a single dose of one of the following: Cefiximine (Suprax) Ciprofloxacin (Cipro) Ceftriaxone (Rocephin)

Azithromyc in (Zithromax) Doxycycline (Vibramycin) Erythromycin (EES) Ofloxacin (Floxin) Sexual partners need evaluation, testing, and treatment also Abstinence from sexual activity until therapy complete and symptoms no longer present Retesting in 3 to 4 months to rule out recurrence

Recommended Treatment

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Disease

TABLE 5.2

Causative Organism Transmission Mode

Diagnostic Testing and Recommended Screening for Sexually Active Adolescent Male Symptoms May lead to epididymitis and sterility Symptoms of rectal infection include discharge, anal itching, and occasional painful bowel movements with fresh blood

Female Symptoms Dyspareunia Endocervicitis Arthritis May lead to pelvic inflammatory disease, ectopic pregnancy, infertility Symptoms of rectal infection include discharge, anal itching, and occasional painful bowel movements with fresh blood.

SEXUALLY TRANSMITTED INFECTIONS COMMON IN ADOLESCENTS (continued)

Ofloxacin (Floxin) Levofloxin (Levaquin) No Floxin or Cipro if ,18 years or pregnant! Azithromycin (Zithromax) Doxycycline (Vibramycin) Usually will be treated for co-infection with Chlamydia, so a combination is given (such as ceftriaxone and doxycycline) Sexual partners need evaluation, testing, and treatment also Abstinence from sexual activity until therapy complete and symptoms no longer present Quinolone therapy is not recommended due to emergence of quinolone-resistant strain

Recommended Treatment

167

Herpes simplex virus II (HSV II)

Treponema pallidum (spirochete bacteria)

Herpes type II (genital herpes) Lifelong recurrent viral disease Most people have not been diagnosed. There is no cure.

Syphilis Sexual contact with an infected person

Having sexual contact (vaginal, oral, or anal) with someone who is shedding the herpes virus either during an outbreak or during a period with no symptoms Can be transmitted through close contact such as close skin-to-skin contact

Blood tests Venereal Disease Research Laboratory (VDRL), rapid plasma reagin (RPR), and treponemal tests (e.g., fluorescent treponemal antibody absorbed [FTA-ABS]) can lead to a presumptive diagnosis. Dark-field examination and direct fluorescent antibody tests of lesion exudate or tissue provide definitive diagnosis of early syphilis. New tests are in development such as enzyme immunoassay Screen based on epidemiology and personal risk factors

Visual inspection and symptoms or culture from swabs taken from lesions (success depends on stage of lesionoptimum is during vesicular stage) Polymerase chain reaction is more sensitive than culture Serologic tests, such as antibody-based testing (Herpes Western blot assay is the most sensitive) Routine screening not recommended

Course of disease divided into four stages Primary infection: • Chancre on place of entrance of bacteria (usually vulva or vagina but can develop in other parts of the body) Secondary infection: • Maculopapular rash (hands and feet) • Sore throat • Lymphadenopathy • Flulike symptoms

Initial symptoms include itching, tingling, and pain in genital area followed by small pustules and blisterlike genital lesions that then crust over and gradually heal. Recurrence episodes are usually milder than the initial episode Dysuria, dyspareunia, and urine retention Fever, headache, malaise, muscle aches Course of disease divided into four stages Primary infection: • Chancre on place of entrance of bacteria (usually on penis but can develop in other parts of the body) Secondary, latent, and tertiary infections: All similar to female symptoms

Initial symptoms include itching, tingling and pain in genital area followed by small pustules and blisterlike genital lesions that then crust over and gradually heal. Recurrence episodes are usually milder than the initial episode Dysuria, dyspareunia, and urine retention Fever, headache, malaise, muscle aches

(continued)

Penicillin G injection (if penicillin allergy, doxycycline, or erythromycin) Sexual partners need evaluation and testing

Antivirals used to treat first episode, recurrence, and suppression Acyclovir (Zovirax), famciclovir, and valacyclovir Does not cure; just controls symptoms Sexual partners benefit from evaluation and counseling. If symptomatic, need treatment If asymptomatic, offer testing and education

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Trichomonas vaginalis (protozoa)

Causative Organism

Vaginal intercourse with an infected partner May be picked up from direct genital contact with damp or moist objects, such as towels, wet clothing, or a toilet seat

Transmission Mode

Microscopic evaluation of vaginal secretions or culture Newer tests available with results within 1 hour and increased sensitivity (antigen-based diagnostic test and DNA probe test)

Diagnostic Testing and Recommended Screening for Sexually Active Adolescent

Many women have symptoms but some may be asymptomatic Dysuria Frequency Vaginal discharge (yellow-green or gray, and foul odor) Dyspareunia Irritation or itching of genital area

Latent infection: • No symptoms • No longer contagious • Many people if not treated will suffer no further signs and symptoms. Some people will go on to develop tertiary or late syphilis. Tertiary infections: • Tumors of skin, bones, and liver • Central nervous system symptoms • Cardiovascular symptoms • Usually not reversible at this stage

Female Symptoms

SEXUALLY TRANSMITTED INFECTIONS COMMON IN ADOLESCENTS (continued)

Trichomoniasis

Disease

TABLE 5.2

Most men infected are asymptomatic. Dysuria Penile discharge (watery white)

Male Symptoms

Metronidazole ­(Flagyl) or tinidazole Sexual partners need evaluation, testing, and treatment also Abstinence recommended until therapy complete

Recommended Treatment

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Human papillomavirus

Vaginal, anal, oral sex with an infected partner Visual inspection Abnormal Pap smear may indicate cervical infection of HPV

Wartlike lesions that are soft, moist, or flesh colored and appear on the vulva and cervix, and inside and surrounding the vagina and anus Sometimes appear in clusters that resemble cauliflower-like bumps, and are either raised or flat, small or large Wartlike lesions that are soft, moist, or flesh-colored and appear on the scrotum or penis. They sometimes appear in clusters that resemble cauliflower-like bumps, and are either raised or flat, small or large.

Adapted from Mehring, P. M. (2009). Sexually transmitted infections. In C. M. Porth & G. Matfin, Pathophysiology: Concepts of altered health states (8th ed., chap. 47, pp. 1167–1180). Philadelphia: Wolters Kluwer Health, Lippincott Williams & Wilkins.

Adapted from Centers for Disease Control and Prevention. (2010a). Sexually transmitted diseases treatment guidelines, 2010. MMWR, 59 (RR-12), 1–116. Retrieved June 19, 2011, from http://www.cdc.gov/std/treatment/2010/STD-Treatment-2010-RR5912.pdf

Venereal warts (condylomata acuminata) One of the most common STIs in the United States Could lead to cancers of the cervix, vulva, vagina, anus, or penis No cure; warts can be r­ emoved but virus remains

May disappear without treatment Treatment is aimed at removing the lesions rather than HPV itself No optimal treatment has been identified, but several ways to treat depending on size and location Most methods rely on chemical or physical destruction of the lesion: Imiquimod cream 20% Podophyllin antimitotic solution 0.5% Podofilox solution 5% 5-fluorouracil cream Trichloroacetic acid (TCA) Small warts can be removed by: • Freezing (cryosurgery) • Burning (electrocautery) • Laser treatment Large warts that have not responded to treatment may be r­ emoved surgically Vaccination available and may lead to ­decrease in cancer associated with HPV Abstinence from sexual activity during ­treatment to promote healing

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Nursing Management Nurses working with adolescents need to convey their willingness to discuss sexual habits. Provide effective guidance, and promote sexual health that primary and/or repeat infections can be avoided. Adolescents bear disproportionate burdens when it comes to STIs, so nurses need to educate them to protect their client’s reproductive futures. Encourage the client to complete the antibiotic prescription (specific management for each type of STI is discussed further in the chapter). Prevention of STIs among adolescents is critical. Health care providers have a unique opportunity to provide counseling and education to their clients. Adapt the style, content, and message to the adolescent’s developmental level. Identify risk factors and risk behaviors and guide the adolescent to develop specific individualized actions of prevention. The nurse’s interaction with the adolescent needs to be direct and nonjudgmental. Encourage adolescents to postpone initiation of sexual intercourse for as long as possible, but if they choose to have sexual intercourse, explain the necessity of using barrier methods, such as male and female condoms (Teaching Guidelines 5.1). For teens who have already had sexual intercourse, the clinician can encourage abstinence at this point. If adolescents are sexually active, they should be directed to teen clinics where contraceptive options can be explained. In areas where specialized teen clinics are not available, nurses should feel comfortable discussing sexuality, safety, and contraception with teens. Encourage adolescents to minimize their lifetime number of sexual partners, to use barrier methods consistently and correctly, and to be aware of the connection between drug and alcohol use and the incorrect use of barrier methods. Table 5.3 discusses barriers to condom use and means to overcome them.

• Do not use a condom if it appears brittle, sticky, or discolored. These are signs of aging. • Put condom on before any genital contact. • Put condom on when penis is erect with rolled side out. Ensure it is placed so it will readily unroll. • Hold the tip of the condom while unrolling. Ensure there is a space at the tip for semen to collect (about ½ inch), but make sure no air is trapped in the tip (air bubbles can cause breakage). • Ensure adequate lubrication during intercourse. If external lubricants are used, use only water-based lubricants such as KY jelly with latex condoms. Oilbased or petroleum-based lubricants, such as body lotion, massage oil, or cooking oil, can weaken latex condoms. • If you feel the condom break, stop immediately, withdraw, remove broken condom, and replace. • Withdraw while penis is still erect, and hold condom firmly against base of penis. Remove carefully to ensure no semen spills out. Dispose of properly. Adapted from Centers for Disease Control and Prevention. (2010b). Male latex condoms and sexually transmitted diseases. Condom fact sheet in brief. Retrieved May 4, 2010, from http://www.cdc.gov/condomeffectiveness/brief.html

Think back to Sandy, who was introduced at the beginning of the chapter. How should the nurse handle Sandy’s anxious state? What specific questions should the nurse ask Sandy to determine the source of the possible infection in her genital area?

INFECTIONS CHARACTERIZED BY VAGINAL DISCHARGE Teaching Guidelines 5.1 PROPER CONDOM USE • Use latex condoms. • Use a new condom with each act of sexual intercourse. Never reuse a condom. • Handle condoms with care to prevent damage from sharp objects such as fingernails and teeth. • Ensure condom has been stored in a cool, dry place away from direct sunlight. Do not store condoms in wallet or automobile or anywhere they would be exposed to extreme temperatures.

Vaginitis is a generic term that means inflammation and infection of the vagina. There can be hundreds of causes for vaginitis, but more often than not the cause is infection by one of three organisms: • Candida, a fungus • Trichomonas, a protozoan • Gardnerella, a bacterium The complex balance of microbiologic organisms in the vagina is a key element in the maintenance of health. Subtle shifts in the vaginal environment may allow organisms with pathologic potential to proliferate, causing infectious symptoms.



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TABLE 5.3

BARRIERS TO CONDOM USE AND MEANS TO OVERCOME THEM

Perceived Barrier

Intervention Strategy

Decreases sexual pleasure (sensation) Note: Often perceived by those who have never used a condom.

• Encourage client to try. • Put a drop of water-based lubricant or saliva inside the tip of the condom or on the glans of the penis before putting on the condom. • Try a thinner latex condom or a different brand or more lubrication.

Decreases spontaneity of sexual activity

• Incorporate condom use into foreplay. • Remind client that peace of mind may enhance pleasure for self and partner.

Embarrassing, juvenile, “unmanly”

• Remind client that it is “manly” to protect himself and others.

Poor fit (too small or too big, slips off, uncomfortable)

• Smaller and larger condoms are available.

Requires prompt withdrawal after ejaculation

• Reinforce the protective nature of prompt withdrawal and suggest substituting other postcoital sexual activities.

Fear of breakage may lead to less vigorous sexual activity

• With prolonged intercourse, lubricant wears off and the condom begins to rub. Have a water-soluble lubricant available to reapply.

Nonpenetrative sexual activity

• Condoms have been advocated for use during fellatio; unlubricated condoms may prove best for this purpose due to the taste of the lubricant. • Other barriers, such as dental dams or an unlubricated condom, can be cut down the middle to form a barrier; these have been advocated for use during certain forms of nonpenetrative sexual activity (e.g., cunnilingus and anolingual sex).

Allergy to latex

• Polyurethane male and female condoms are available. • A natural skin condom can be used together with a latex condom to protect the man or woman from contact with latex.

Used with permission from the Expert Working Group on the Canadian Guidelines for Sexually Transmitted Infections. (2008). Canadian guidelines on sexually transmitted infections. Ottawa, ON: Public Health Agency of Canada.

The nurse’s role in managing vaginitis is one of primary prevention and education to limit recurrences of these infections. Primary prevention begins with changing the sexual behaviors that place women at risk for infection. In addition to assessing women for the common signs and symptoms and risk factors, the nurse can help women to avoid vaginitis or to prevent a recurrence by teaching them to take the precautions highlighted in Teaching Guidelines 5.2.

Genital/Vulvovaginal Candidiasis (VVC) Genital/vulvovaginal candidiasis is one of the most common causes of vaginal discharge. It is also referred to as yeast, monilia, and a fungal infection. It is not

Teaching Guidelines 5.2 PREVENTING VAGINITIS • Avoid douching to prevent altering the vaginal environment. • Use condoms to avoid spreading the organism. • Avoid tights, nylon underpants, and tight clothes. • Wipe from front to back after using the toilet. • Avoid powders, bubble baths, and perfumed vaginal sprays. • Wear clean cotton underpants. • Change out of wet bathing suits as soon as possible. • Become familiar with the signs and symptoms of vaginitis. • Choose to lead a healthy lifestyle.

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considered an STI because Candida is a normal constituent in the vagina and becomes pathologic only when the vaginal environment becomes altered. An estimated 75% of women will have at least one episode of vulvovaginal candidiasis, and 40% to 50% will have two or more episodes in their lifetime (CDC, 2012b).

Therapeutic Management Treatment of candidiasis includes one of the following medications: • Miconazole (Monistat) cream or suppository • Clotrimazole (Mycelex) tablet or cream • Terconazole (Terazol) cream or intravaginal suppository • Fluconazole (Diflucan) oral tablet (CDC, 2012b) Most of these medications are used intravaginally in the form of a cream, tablet, or suppositories for 3 to 7 days. If fluconazole (Diflucan) is prescribed, a 150-mg oral tablet is taken as a single dose. Topical azole preparations are effective in the treatment of vulvovaginal candidiasis, relieving symptoms and producing negative cultures in 80% to 90% of women who complete therapy (CDC, 2012b). If vulvovaginal candidiasis is not treated effectively during pregnancy, the newborn can develop an oral infection known as thrush during the birth process; that infection must be treated with a local azole preparation after birth.

Nursing Assessment Assess the client’s health history for predisposing factors for vulvovaginal candidiasis, which include: • Pregnancy • Use of oral contraceptives with a high estrogen content • Use of broad-spectrum antibiotics • Diabetes mellitus • Obesity • Use of steroid and immunosuppressive drugs • HIV infection • Wearing tight, restrictive clothes and nylon underpants • Trauma to vaginal mucosa from chemical irritants or douching Assess the client for clinical manifestations of vulvovaginal candidiasis. Typical symptoms, which can worsen just before menses, include: • Pruritus • Vaginal discharge (thick, white, curdlike) • Vaginal soreness • Vulvar burning • Erythema in the vulvovaginal area • Dyspareunia • External dysuria Figure  5.1 shows the typical appearance of vulvovaginal candidiasis. Speculum examination will reveal white plaques on the vaginal walls. The vaginal pH remains within normal

Candida infection

Hyphae

Thick, white vaginal discharge

FIGURE 5.1 Vulvovaginal candidiasis. (Asset provided by Anatomical Chart Co.)



range. Definitive diagnosis is made by a wet smear, which reveals the filamentous hyphae and spores characteristic of a fungus when viewed under a microscope.

Nursing Management Teach preventive measures to women with frequent vulvovaginal candidiasis infections, including: • Reduce dietary intake of simple sugars and soda. • Wear white, 100% cotton underpants. • Avoid wearing tight pants or exercise clothes with spandex. • Shower rather than taking tub baths. • Wash with a mild, unscented soap and dry the genitals gently. • Avoid the use of bubble baths or scented bath products. • Wash underwear in unscented laundry detergent and hot water. • Dry underwear in a hot dryer to kill the yeast that clings to the fabric. • Remove wet bathing suits promptly. • Practice good body hygiene. • Avoid vaginal sprays/deodorants. • Avoid wearing pantyhose (or cut out the crotch to allow air circulation). • Use white, unscented toilet paper and wipe from front to back. • Avoid douching (which washes away protective vaginal mucus). • Avoid the use of super-absorbent tampons (use pads instead).

Trichomoniasis Trichomoniasis is another common vaginal infection that causes a discharge. The woman may be markedly symptomatic or asymptomatic. When symptoms are present, they include vulvar itching and a malodorous foamy vaginal discharge. Men are asymptomatic carriers. Although this infection is localized, there is increasing evidence of preterm birth and postpartum endometritis in women with this vaginitis (CDC, 2012c). Trichomonas vaginalis is an ovoid, single-cell protozoan parasite that can be observed under the microscope making a jerky swaying motion.

Therapeutic Management A single 2-g dose of oral metronidazole (Flagyl) or tinidazole (Tindamax) for both partners is a common ­ treatment for this infection. Sex partners of women with trichomoniasis should be treated to avoid recurrence of infection.

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Nursing Assessment Assess the client for clinical manifestations of trichomoniasis, which include: • A heavy yellow/green or gray frothy or bubbly discharge • Vaginal pruritus and vulvar soreness • Dyspareunia • Cervix may bleed on contact • Dysuria • Vaginal odor, described as foul • Vaginal or vulvar erythema • Petechiae on the cervix Figure  5.2 shows the typical appearance of trichomoniasis. The diagnosis is confirmed when a motile flagellated trichomonad is visualized under the microscope. In addition, a vaginal pH of greater than 4.5 is a typical finding. FDA-cleared tests for trichomoniasis in women include OSOM Trichomonas Rapid Test (Genzyme Diagnostics, Cambridge, Massachusetts), an immunochromatographic capillary flow dipstick technology, and the Affirm VP III (Becton Dickenson, San Jose, California), a nucleic acid probe test that evaluates for T. vaginalis, G. vaginalis, and C. albicans. Each of these tests, which are performed on vaginal secretions, have a sensitivity of .83% and a specificity of .97%. Both tests are considered point-of-care diagnostics (CDC, 2010c).

Nursing Management Instruct clients to avoid sex until they and their sex partners are cured (i.e., when therapy has been completed and both partners are symptom-free) and also to avoid consuming alcohol during treatment because mixing the medications and alcohol causes severe nausea and vomiting (CDC, 2012c). In addition, it is important to provide information regarding infection cause and transmission, effects on reproductive organs and future fertility, and the need for partner notification and treatment. Follow-up testing is not indicated if symptoms resolve with treatment. See Evidence-Based Practice 5.1 for interventions for Trichomoniasis in pregnancy.

Bacterial Vaginosis A third common infection of the vagina is bacterial vaginosis, caused by the gram-negative bacillus Gardnerella vaginalis. It is the most prevalent cause of vaginal discharge or malodor, but up to 50% of women are asymptomatic. Bacterial vaginosis is a sexually associated infection characterized by alterations in vaginal flora in which lactobacilli in the vagina are replaced with high

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Microscopic view of the organism

FIGURE 5.2 Trichomoniasis. (Asset provided by ­Anatomical Chart Co.)

Greenish-gray cervical discharge

concentrations of anaerobic bacteria. The cause of the microbial alteration is not fully understood but is associated with having multiple sex partners, douching, and lack of vaginal lactobacilli. Bacterial vaginosis can increase a woman’s susceptibility to other STIs such as

EVIDENCE-BASED PRACTICE 5.1

HIV, herpes, chlamydia, and g ­onorrhea (CDC, 2012d). Research suggests that bacterial vaginosis is associated with preterm labor, premature rupture of membranes, chorioamnionitis, postpartum endometritis, and pelvic inflammatory disease (CDC, 2012d).

INTERVENTIONS FOR TRICHOMONIASIS IN PREGNANCY

STUDY Trichomoniasis is a very common sexually transmitted infection. Symptoms include vaginal itching and discharge. It is not clear whether pregnant women with trichomoniasis are more likely to give birth preterm or to have other pregnancy complications. The review of trials found that the drug metronidazole is effective against trichomoniasis when taken by women and their partners during pregnancy, but it may harm the baby. Of the two clinical trials reviewed, one was stopped early because women taking metronidazole were more likely to give birth preterm and have low-birthweight babies. Further research into trichomoniasis treatments for pregnant women is needed.

Findings Metronidazole, given as a single dose, is likely to provide parasitologic cure for trichomoniasis, but it is not known whether this treatment will have any effect on pregnancy outcomes. The cure rate could probably be higher if more partners used the treatment.

Nursing Implications The nurse’s role concerning this study’s results is to counsel women diagnosed with trichomoniasis during pregnancy about the potential risks of treatment. The woman should be cautioned about taking this medication if she has a previous history of preterm births, is carrying twins, or is experiencing preterm contractions. In addition, an ultrasound should validate the fetal weight linked to the gestational age to make sure it is within normal range before this medication is prescribed. Source: Gülmezoglu, A. M., & Azhar, M. (2011). Interventions for trichomoniasis in pregnancy. Cochrane Database of Systematic Reviews 2011, Issue 5. Art. No.: CD000220. DOI: 10.1002/14651858.CD000220.



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Therapeutic Management

Nursing Management

Treatment for bacterial vaginosis includes oral metronidazole (Flagyl) or clindamycin (Cleocin) cream. Treatment of the male partner has not been beneficial in preventing recurrence because sexual transmission of bacterial vaginosis has not been proven (CDC, 2012d).

The nurse’s role is one of primary prevention and education to limit recurrences of these infections. Primary prevention begins with changing the sexual behaviors that place women at risk for infection. In addition to assessing women for common signs, symptoms, and risk factors, the nurse can help women to avoid vaginitis or to prevent a recurrence by teaching them to take the precautions highlighted in Teaching Guidelines 5.2.

Nursing Assessment Assess the client for clinical manifestations of bacterial vaginosis. Primary symptoms are a thin, white homogeneous vaginal discharge and a characteristic “stale fish” odor. Figure 5.3 shows the typical appearance of bacterial vaginosis. To diagnose bacterial vaginosis, three of the four criteria must be met: • Thin, white homogeneous vaginal discharge • Vaginal pH .4.5 • Positive “whiff test” (secretion is mixed with a drop of 10% potassium hydroxide on a slide, producing a characteristic stale fishy odor) • The presence of clue cells on wet-mount examination (CDC, 2012d)

INFECTIONS CHARACTERIZED BY CERVICITIS Cervicitis is a catchall term that implies the presence of inflammation or infection of the cervix. It is used to describe everything from symptomless erosions to an inflamed cervix that bleeds on contact and produces quantities of purulent discharge containing organisms not ordinarily found in the vagina. Cervicitis is usually caused by gonorrhea or chlamydia, as well as almost any pathogenic bacterial agent and a number of viruses. The treatment of cervicitis involves the appropriate therapy for the specific organism that has caused it.

Chlamydia

Clue cell seen in bacterial vaginosis caused by Gardnerella vaginalis

Discharge with fishy odor

FIGURE 5.3 Bacterial vaginosis. (Illustration provided by Anatomical Chart Co. Photograph from Sweet RL, Gibbs RS. Atlas of Infectious Diseases of the Female Genital Tract. ­Philadelphia: Lippincott Williams & Wilkins, 2005.)

Chlamydia is the most common bacterial STI in the United States. The CDC estimates that there are 2.8 ­million cases in the United States annually; the highest predictor for the infection is age. The highest rates of infection are among those ages 15 to 19, mainly because their sexual relations are often unplanned and are sometimes the ­result of pressure or force, and typically h ­ appen before they have the experience and skills to protect themselves. The rates are highest among this group regardless of demographics or location (CDC, 2012e). The young have the most to lose from acquiring STIs, since they will suffer the consequences the longest and might not reach their full reproductive potential. The most common risk factors associated with Chlamydia are age ,25  years, r­ecent change in sexual partner or multiple sexual p ­ artners, poor socioeconomic conditions, single status, and lack of use of barrier contraception (Struble, & Jackson, 2012). Asymptomatic infection is common among both men and women. Men primarily develop urethritis. In women, chlamydia is linked with cervicitis, acute urethral syndrome, salpingitis, ectopic pregnancy, pelvic inflammatory disease (PID), and infertility (Stamm, Mirand, & Mcgregor, 2011). Chlamydia causes half of the 1 million recognized cases of PID in the United States each year, and treatment costs run over $701  million yearly. The CDC (2012e) recommends yearly chlamydia testing of all sexually active women age 25 or younger, older women

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with risk factors for chlamydial infections (those who have a new sex partner or multiple sex partners), and all pregnant women. Chlamydia trachomatis is the bacterium that causes chlamydia. It is an intracellular parasite that cannot produce its own energy and depends on the host for survival. It is often difficult to detect, and this can pose problems for women due to the long-term consequences of untreated infection. Moreover, lack of treatment provides more opportunity for the infection to be transmitted to sexual partners. Newborns delivered to infected mothers may develop conjunctivitis which occurs in 25 to 50% of all newborns. Ophthalmia neonatorum is an acute mucopurulent conjunctivitis occurring in the first month of birth. It is essentially an infection acquired during vaginal delivery. The most frequent infectious agents involved in are Chlamydia trachomatis and Neisseria gonorrhea (Zuppa, D’Andrea, Catenazzi, Scorrano, & R ­ omagnoli, 2011).

Therapeutic Management Antibiotics are usually used in treating this STI. The CDC treatment options for chlamydia include doxycycline ­(Vibromycin) 100 mg orally twice a day for 7 days or azithromycin (Zithromax) 1 g orally in a single dose. Because of the common co-infection of chlamydia and gonorrhea, a combination regimen of ceftriaxone (Rocephin) with doxycycline or azithromycin is prescribed frequently (CDC, 2012e). Additional CDC guidelines for client management include annual screening of all sexually active women aged 20 to 25 years old; screening of all high-risk people; and treatment with antibiotics effective against both gonorrhea and chlamydia for anyone diagnosed with a gonococcal infection (CDC, 2012e). Except in pregnant women, test-of-cure (repeat testing 3 to 4 weeks after completing therapy) is not recommended for women treated with the recommended or alterative regimens, unless therapeutic compliance is in question, symptoms persist, or reinfection is suspected (CDC, 2010c).

Nursing Assessment Assess the health history for significant risk factors for chlamydia, which may include: • Being an adolescent • Having multiple sex partners • Having a new sex partner • Engaging in sex without using a barrier contraceptive (condom) • Using oral contraceptives • Being pregnant • Having a history of another STI (Schuiling & Likis, 2013). Assess the client for clinical manifestations of chlamydia. The majority of women (70% to 80%) are

asymptomatic (CDC, 2012e). If the client is symptomatic, clinical manifestations include: • Mucopurulent vaginal discharge • Urethritis • Bartholinitis • Endometritis • Salpingitis • Dysfunctional uterine bleeding The diagnosis can be made by urine testing or swab specimens collected from the endocervix or vagina. ­Culture, direct immunofluorescence, EIA, or nucleic acid amplification methods such as GenProbe or Pace2) are highly sensitive and specific when used on urethral and cervicovaginal swabs. They can also be used with good sensitivity and specificity on first-void urine specimens (Struble, & Jackson, 2012). The chain reaction tests are the most sensitive and ­cost-effective. The CDC (1012e) strongly recommends screening of asymptomatic women at high risk in whom infection would otherwise go undetected. Chlamydia is an important preventable cause of infertility and other adverse reproductive health outcomes. Effective prevention interventions are available to reduce the burden of chlamydia and its sequelae, but they are underutilized. Although many prevention programs are available, improvements can be made in raising awareness about chlamydia, increasing screening coverage, and enhancing partner services. In addition, nurses can focus their efforts on reaching disproportionately affected racial/ethnic groups. To break the cycle of chlamydia transmission in the United States, health care providers should encourage annual chlamydia screening for all sexually active females aged ,25  years, maximize use of effective partner treatment services, and rescreen infected females and males 3 months after treatment (CDC Grand Rounds, 2011).

Gonorrhea Gonorrhea is a serious, and potentially very severe, bacterial infection. It is the second most commonly reported infection in the United States. Gonorrhea is highly contagious and is a reportable infection to the health department authorities. Gonorrhea increases the risk for PID, infertility, ectopic pregnancy, and HIV acquisition and transmission (CDC, 2012f). It is rapidly becoming more and more resistant to cure. In the United States, an estimated 700,000 new gonorrhea infections occur annually (CDC, 2012f). In common with all other STIs, it is an equal-opportunity infection—no one is immune to it, regardless of race, creed, gender, age, or sexual preference. The cause of gonorrhea is an aerobic g ­ ram-negative intracellular diplococcus, Neisseria gonorrhoeae. The site of infection is the columnar epithelium of the endocervix. Gonorrhea is almost exclusively transmitted by sexual activity. In pregnant women, gonorrhea



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is associated with chorioamnionitis, premature labor, premature rupture of membranes, and postpartum endometritis (Ball, 2011). It can also be transmitted to the newborn in the form of ophthalmia neonatorum during birth by direct contact with gonococcal organisms in the cervix. Ophthalmia neonatorum is highly contagious and if untreated leads to blindness in the newborn.

Therapeutic Management The treatment of choice for uncomplicated gonococcal infections is azithromycin 1 g orally in a single dose and ceftriaxone 250 mg intramascular (IM) in a single dose (Campos-Outcalt, 2011). Azithromycin (Zithromax) orally or doxycycline (Vibromycin) should accompany all gonococcal treatment regimens if chlamydial infection is not ruled out (CDC, 2012e). Pregnant women with gonorrhea should not be treated with quinolones or tetracyclines. Pregnant women with a positive test for gonorrhea should be treated with the same recommended single dose of ceftriaxone with either azithromycin or amoxicillin (CDC, 2010c). To prevent gonococcal ophthalmia neonatorum, a prophylactic agent should be instilled into the eyes of all newborns; this procedure is required by law in most states. Erythromycin or tetracycline ophthalmic ointment in a single application is recommended (Zuppa et al., 2011). With use of recommended treatment, follow-up testing to document eradication of gonorrhea is no longer recommended. Instead, rescreening in 2 to 3 months to identify reinfection is suggested (CDC, 2010c).

Nursing Assessment Assess the client’s health history for risk factors, which may include low socioeconomic status, living in an urban area, single status, inconsistent use of barrier contraceptives, age under 20  years old, and multiple sex partners. Assess the client for clinical manifestations of gonorrhea, keeping in mind that between 50% and 90% of women infected with gonorrhea are totally symptomfree (Bennett & Domachowske, 2011). Because women are so frequently asymptomatic, they are regarded as a major factor in the spread of gonorrhea. If symptoms are present, they might include: • Abnormal vaginal discharge • Dysuria • Cervicitis • Abnormal vaginal bleeding • Bartholin’s abscess • PID • Neonatal conjunctivitis in newborns • Mild sore throat (for pharyngeal gonorrhea) • Rectal infection (asymptomatic) • Perihepatitis (Bennett & Domachowske, 2011)

FIGURE 5.4 Gonorrhea. (From Sherwood L. ­Gorbach, John G. Bartlett, et al. Infectious Diseases. Philadelphia: ­Lippincott Williams & Wilkins, 2004.)

Sometimes a local gonorrhea infection is self-­ limiting (there is no further spread), but usually the organism ascends upward through the endocervical canal to the endometrium of the uterus, further on to the fallopian tubes, and out into the peritoneal cavity. When the peritoneum and the ovaries become involved, the condition is known as PID. The scarring to the fallopian tubes is permanent. This damage is a major cause of infertility and is a possible contributing factor in ectopic pregnancy ( Jaiyeoba, Lazenby, & Soper, 2011). If gonorrhea remains untreated, it can enter the bloodstream and produce a disseminated gonococcal infection. This severe form of infection can invade the joints (arthritis), the heart (endocarditis), the brain (meningitis), and the liver (toxic hepatitis). Figure 5.4 shows the typical appearance of gonorrhea. The CDC recommends screening for all women at risk for gonorrhea. Pregnant women should be screened at the first prenatal visit and again at 36 weeks of gestation. Nucleic acid hybridization tests (GenProbe) are used for diagnosis. Any woman suspected of having ­gonorrhea should be tested for chlamydia also because co-infection (45%) is extremely common (CDC, 2012f).

Nursing Management of Chlamydia and Gonorrhea The prevalence of chlamydia and gonorrhea is increasing dramatically, and these infections can have long-term effects on people’s lives. Sexual health is an important

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part of a person’s physical and mental health, and nurses have a professional obligation to address it. Be particularly sensitive when addressing STIs because women are often embarrassed or feel guilty. There is still a social stigma attached to STIs, so women need to be reassured about confidentiality. The nurse’s knowledge about chlamydia and gonorrhea should include treatment strategies, referral sources, and preventive measures. It is important to be skilled at client education and counseling and to be comfortable talking with, and advising, women diagnosed with these infections. Provide education about risk factors for these infections. High-risk groups include single women, women younger than 25 years, African American women, women with a history of STIs, those with new or ­multiple sex partners, those with inconsistent use of barrier contraception, and women living in communities with high infection rates (Bennett & Domachowske, 2011). ­Assessment involves taking a health history that includes a comprehensive sexual history. Ask about the number of sex partners and the use of safer sex techniques. Review previous and current symptoms. Emphasize the importance of seeking treatment and informing sex partners. The four-level P-LI-SS-IT model (Box 5.2) can be used to determine interventions for various women because it can be adapted to the nurse’s level of knowledge, skill, and experience. Of utmost importance is the willingness to listen and show interest and respect in a nonjudgmental manner. In addition to meeting the health needs of women with chlamydia and gonorrhea, the nurse is responsible for educating the public about the increasing incidence of these infections. This information should include highrisk behaviors associated with these infections, signs and

BOX 5.2

THE P-LI-SS-IT MODEL P Permission—gives the woman permission to talk about her experience LI Limited Information—information given to the woman about STIs • Factual information to dispel myths about STIs • Specific measures to prevent transmission • Ways to reveal information to her partners • Physical consequences if the infections are untreated SS Specific Suggestions—an attempt to help women change their behavior to prevent recurrence and prevent further transmission of the STI IT Intensive Therapy—involves referring the woman or couple for appropriate treatment elsewhere based on their life circumstances

symptoms, and the treatment modalities available. Stress that both of these STIs can lead to infertility and longterm sequelae. Teach safer sex practices to people in nonmonogamous relationships. Know the physical and psychosocial responses to these STIs to prevent transmission and the disabling consequences. Nurses must also inform their pregnant clients that they should avoid quinolones or tetracyclines to prevent risks associated with malformation of teeth, bones, and joints in the fetus and possible hepatotoxicity and pancreatitis in the mother (Walker & Sweet, 2011).

Take Note! If the epidemic of chlamydia and gonorrhea is to be halted, nurses must take a major front-line role now.

INFECTIONS CHARACTERIZED BY GENITAL ULCERS In the United States, the majority of young, sexually active clients who have genital ulcers have genital herpes, syphilis, or chancroid. The frequency of each condition differs by geographic area and client population; however, genital herpes is the most prevalent of these diseases. More than one of these diseases can be present in a client who has genital ulcers. All three of these diseases have been associated with an increased risk for HIV infection. Not all genital ulcers are caused by STIs.

Genital Herpes Simplex Genital herpes is a recurrent, lifelong viral infection. The CDC estimates that one out of six people 14 to 49  years old have genital herpes simplex (HSV) infection, with 0.5 million new cases annually (CDC, 2012g). Two serotypes of HSV have been identified: HSV-1 (not sexually transmitted) and HSV-2 (sexually transmitted). Today, approximately 10% of genital herpes infections are thought to be caused by HSV-1 and 90% by HSV-2. HSV-1 causes the familiar fever blisters or cold sores on the lips, eyes, and face. HSV-2 invades the mucous membranes of the genital tract and is known as herpes genitalis. Most people infected with HSV-2 have not been diagnosed. The herpes simplex virus is transmitted by contact of mucous membranes or breaks in the skin with visible or nonvisible lesions. Most genital herpes infections are transmitted by individuals unaware that they have an infection. Many have mild or unrecognized infections but still shed the herpes virus intermittently. HSV is transmitted primarily by direct contact with an infected ­individual who is shedding the virus. Kissing, sexual contact, and vaginal delivery are means of transmission.



Having sex with an infected partner places the individual at risk for contracting HSV. After the primary outbreak, the virus remains dormant in the nerve cells for life, resulting in periodic recurrent outbreaks. Recurrent genital herpes outbreaks are triggered by precipitating factors such as emotional stress, menses, and sexual ­intercourse, but more than half of recurrences occur without a precipitating cause. Immunocompromised women have more frequent and more severe recurrent outbreaks than normal hosts (Mark, Lucea, Nanda, F ­ arley, & ­Gilbert, 2011). Living with genital herpes can be difficult due to the erratic, recurrent nature of the infection, the location of the lesions, the unknown causes of the recurrences, and the lack of a cure. Further, the stigma associated with this infection may affect the individual’s feelings about herself and her interaction with partners. Potential psychosocial consequences may include emotional distress, isolation, fear of rejection by a partner, fear of transmission of the disease, loss of confidence, and altered interpersonal relationships (Alexander, LaRosa, Bader, & Garfield, 2010). Along with the increase in the incidence of genital herpes has been an increase in neonatal herpes simplex viral infections, which are associated with a high incidence of mortality and morbidity. The risk of neonatal infection with a primary maternal outbreak is between 30% and 50%; it is less than 1% with a recurrent maternal infection (CDC, 2012g).

Therapeutic Management No cure exists, but antiviral drug therapy helps to reduce or suppress symptoms, shedding, and recurrent episodes. Advances in treatment with acyclovir (Zovirax) 400 mg orally three times daily for 7 to 10 days, famciclovir (Famivir) 250 mg orally three times daily for 7 to 10 days, and valacyclovir (Valtrex) 1 g orally twice daily for 7 to 10 days have resulted in an improved quality of life for those infected with HSV. However, these drugs neither eradicate latent virus nor affect the risk, frequency, or severity of recurrences after the drug is discontinued (CDC, 2012g). Suppressive therapy is recommended for individuals with six or more recurrences per year. The natural course of the disease is for recurrences to be less frequent over time. The management of genital herpes includes antiviral therapy. The safety of antiviral therapy has not been established during pregnancy. Therapeutic management also includes counseling regarding the natural history of the disease, the risk of sexual and perinatal transmission, and the use of methods to prevent further spread. The following are a few guidelines to delivering information in a time-limited environment: (a) use all available client reading materials; (b) have another knowledgeable staff member in the office who can spend extra time

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with women who need it; (c) refer clients to good and ­accurate websites such as the American Social Health ­ Association (www.ashastd.org/hrc); (d) know the phone numbers of herpes support groups in your area; (e) educate the client to abstain from all sexual activity until HSV lesions resolve; (f) use good handwashing technique to prevent spread; (g) educate that there is no cure, and that practicing safe sex (using condoms) with every sex act is essential to prevent transmission; and (h) encourage all clients to inform their current sex partners that they have genital herpes and to inform future partners before initiating a sexual relationship. Finally, many experts recommend a sympathetic, nonjudgmental approach. The nurse can state in clear terms that having herpes does not change the core of the person or make them less worthwhile (Barnack-Tavlaris, Reddy, & Ports, 2011).

Nursing Assessment Assess the client for clinical manifestations of HSV. Clinical manifestations can be divided into the primary episode and recurrent infections. The first or primary episode is usually the most severe, with a prolonged period of viral shedding. Primary HSV is a systemic ­disease characterized by multiple painful vesicular lesions, mucopurulent discharge, superinfection with candida, fever, chills, malaise, dysuria, headache, genital irritation, inguinal tenderness, and lymphadenopathy. The lesions in the primary herpes episode are frequently located on the vulva, vagina, and perineal areas. The vesicles will open and weep and finally crust over, dry, and disappear without scar formation (Fig. 5.5). This viral shedding process usually takes up to 2 weeks to complete. Recurrent infection episodes are usually much milder and shorter in duration than the primary one. Tingling, itching, pain, unilateral genital lesions, and a more rapid resolution of lesions are characteristics of recurrent infections. Recurrent herpes is a localized disease characterized by typical HSV lesions at the site of initial viral entry. Recurrent herpes lesions are fewer in number and less painful and resolve more rapidly (Salvaggio, ­Lutwick, & Kumar, 2012). Diagnosis of HSV is often based on clinical signs and symptoms and is confirmed by viral culture of fluid from the vesicle. Papanicolaou (Pap) smears are an insensitive and nonspecific diagnostic test for HSV and should not be relied on for diagnosis.

Syphilis Syphilis is a complex, curable bacterial infection caused by the spirochete Treponema pallidum. It is a serious systemic disease that can lead to disability and death if untreated. Rates of syphilis in the United States are

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Herpetic lesions on labia majora

FIGURE 5.5 Genital herpes simplex. (Illustration provided by Anatomical Chart Co. ­Photograph courtesy of Stephen Ludwig, MD.)

increasing and remain high among young adults and ­African Americans in urban areas and in the south (CDC, 2012h). It continues to be one of the most important STIs both because of its biologic effect on HIV acquisition and transmission and because of its impact on infant health (Follett & Clarke, 2011). The spirochete rapidly penetrates intact mucous membranes or microscopic lesions in the skin and within hours enters the lymphatic system and bloodstream to produce a systemic infection long before the appearance of a primary lesion. The site of entry may be vaginal, rectal, or oral (Euerle et al., 2012). The syphilis spirochete can cross the placenta at any time during pregnancy. One out of every 10,000 infants born in the United States has congenital syphilis (CDC, 2012h). Maternal infection consequences include spontaneous abortion, prematurity, stillbirth, and multisystem failure of the heart, lungs, spleen, liver, and pancreas, as well as structural bone damage and nervous system involvement and mental retardation (Gilbert, 2011). Most newborns born with congenital syphilis are exposed in utero after the fourth month of pregnancy; although syphilis acquired late in the third trimester can also be transmitted to an infant through exposure to an active genital lesion at the time of birth. If untreated, syphilis is a lifelong infection progressing in orderly staging. The five stages of syphilis infection are: (1) primary, (2) secondary, (3) early latent, (4) late latent, and (5) tertiary. The primary, secondary, and early latent stages are considered the most

infectious: the estimated risk of per person transmission is 60% (Follett & Clarke, 2011).

Therapeutic Management Fortunately, there is effective treatment for syphilis. Penicillin G, administered by either the intramuscular or intravenous route, is the preferred drug for all stages of syphilis. For pregnant or nonpregnant women with syphilis of less than 1 year’s duration, the CDC recommends 2.4 million units of benzathine penicillin G intramuscularly in a single dose. If the syphilis is of longer duration (more than 1  year) or of unknown duration, 2.4 million units of benzathine penicillin G is given intramuscularly once a week for 3 weeks. The preparations used, the dosage, and the length of treatment depend on the stage and clinical manifestations of disease (CDC, 2012h). Other medications, such as doxycycline, are available if the client is allergic to penicillin. Women should be reevaluated at 6 and 12 months after treatment for primary or secondary syphilis with additional serologic testing. Women with latent syphilis should be followed clinically and serologically at 6, 12, and 24 months (Euerle et al., 2012).

Nursing Assessment Assess the client for clinical manifestations of syphilis. Syphilis is divided into four stages: primary, secondary,



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Nursing Management of Herpes and Syphilis Genital ulcers from either herpes or syphilis can be devastating to women, and the nurse can be instrumental in helping her through this difficult time. Referral to a support group may be helpful. Address the psychosocial aspects of these STIs with women by discussing appropriate coping skills, acceptance of the lifelong n ­ ature of the condition (herpes), and options for treatment and rehabilitation. Teaching Guidelines 5.3 highlights appropriate teaching points for the client with genital ulcers.

FIGURE 5.6 Chancre of primary syphilis. (From Sweet RL, Gibbs RS. Atlas of Infectious Diseases of the Female Genital Tract. Philadelphia: Lippincott Williams & Wilkins, 2005.)

latency, and tertiary. Primary syphilis is characterized by a chancre (painless ulcer) at the site of bacterial entry that will disappear within 1 to 6 weeks without intervention (Fig.  5.6). Motile spirochetes are present on darkfield examination of ulcer exudate. In addition, painless bilateral adenopathy is present during this highly infectious period. If left untreated, the infection progresses to the secondary stage. Secondary syphilis appears 2 to 6 months after the initial exposure and is manifested by flulike symptoms and a maculopapular rash of the trunk, palms, and soles. Alopecia and adenopathy are both common during this stage. In addition to rashes, secondary syphilis may present with symptoms of fever, pharyngitis, weight loss, and fatigue (Badri & Jennet, 2011). The secondary stage of syphilis lasts about 2 years. Once the secondary stage subsides, the latency period begins. This stage is characterized by the absence of any clinical manifestations of disease, although the serology is positive. This stage can last as long as 20 years. If not treated, tertiary or late syphilis occurs, with life-threatening heart disease and neurologic disease that slowly destroys the heart, eyes, brain, central nervous system, and skin. Clients with a diagnosis of HIV or another STI should be screened for syphilis, and all pregnant women should be screened at their first prenatal visit. Dark-field microscopic examinations and direct fluorescent antibody tests of lesion exudate or tissue are the definitive methods for diagnosing early syphilis. A presumptive diagnosis can be made by using two serologic tests: • Nontreponemal tests (Venereal Disease Research Laboratory [VDRL] and rapid plasma reagin [RPR]) • Treponemal tests (fluorescent treponemal antibody absorbed [FTA-ABS] and T. pallidum particle agglutination [TP-PA]). Dark-field microscopic examinations and direct fluorescent antibody tests of lesion exudate or tissue are the definitive methods for diagnosing early syphilis (CDC, 2012h).

Teaching Guidelines 5.3 CARING FOR GENITAL ULCERS • Abstain from intercourse during the prodromal period and when lesions are present. • Wash hands with soap and water after touching lesions to avoid autoinoculation. • Use comfort measures such as wearing nonconstricting clothes, wearing cotton underwear, urinating in water if urination is painful, taking lukewarm sitz baths, and air-drying lesions with a hair dryer on low heat. • Avoid extremes of temperature such as ice packs or hot pads to the genital area as well as application of steroid creams, sprays, or gels. • Use condoms with all new or noninfected partners. • Inform health care professionals of your condition.

Pelvic Inflammatory Disease Pelvic inflammatory disease (PID) refers to an inflammatory state of the upper female genital tract and nearby structures. PID may involve the uterine lining (endometritis), the connective tissue adjacent to the uterue (parametritis), the Fallopian tubes (salpingitis), or the serous membrane that lines part of the abdominal cavity and viscera (peritonitis), or it may manifest as tubo-ovarian abscess (Turner, 2012). PID results from an ascending polymicrobial infection of the upper female reproductive tract, frequently caused by untreated c­ hlamydia or gonorrhea (Fig. 5.7). An estimated 750,000 women are diagnosed annually, resulting in over 250,000 hospitalizations (CDC, 2012i). It is a serious health ­problem in the United States, costing an estimated $12 billion annually in terms of hospitalizations and surgical p ­ rocedures (Aghaizu et al., 2011). Complications include ectopic pregnancy, pelvic abscess, subfertility, recurrent or chronic episodes of the disease, chronic abdominal pain, pelvic adhesions, and depression (Soleymani, Ismail, &  Currie, 2011).

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should be avoided (Harrison, 2011). The client is treated on an ambulatory basis with a single-dose injectable antibiotic or is hospitalized and given antibiotics intravenously. The decision to hospitalize a woman is based on clinical judgment and the severity of her symptoms (e.g., severely ill with high fever, a tubo-ovarian abscess is suspected, woman is immunocompromised or presents with protracted vomiting). Treatment then includes intravenous antibiotics, increased oral fluids to improve hydration, bed rest, and pain management. Follow-up is needed to validate that the infectious process is gone to prevent the development of chronic pelvic pain.

Nursing Assessment Spread of gonorrhea or chlamydia

FIGURE 5.7 Pelvic inflammatory disease. Chlamydia or gonorrhea spreads up the vagina into the uterus and then to the fallopian tubes and ovaries.

Because most PID cases are secondary to sexually transmitted infections, especially chlamydia, the most effective approach to control of it is prevention. Because of the seriousness of the complications of PID, an accurate diagnosis is critical Healthy People 2020 5-2.

Therapeutic Management Broad-spectrum antibiotic therapy is generally required to cover chlamydia, gonorrhea, and/or any anaerobic infection. A parenteral cephalosporin in a single injection with doxycycline 100 mg twice a day for 14 days is the current CDC recommendation (Campos-Outcalt, 2011). PID in pregnancy is uncommon, but a combination of cefotaxime, azithromycin, and metronidazole for 14 days may be used. Tetracyclines and quinolones

HEALTHY P EOP LE 2020 Objectives 25-26,27

Significance

Reduce the proportion of females who have ever required treatment for pelvic inflammatory disease (PID). Reduce the proportion of childless females with fertility problems who have had a sexually transmitted disease or who have ever required treatment for pelvic inflammatory disease (PID).

Educate women that ­abstinence is the only way to completely avoid contracting sexually transmitted infections. Encourage women always to use condoms if participating in any sexual act. Provide an open and confidential environment so women will report symptoms and seek t­ reatment earlier.

Nursing assessment of the woman with PID involves a complete health history and assessment of clinical manifestations, physical examination, and laboratory and d ­ iagnostic testing.

Health History and Clinical Manifestations Explore the client’s current and past medical health history for risk factors for PID, which may include: • Adolescence or young adulthood • Non-White female • Having multiple sex partners • Early onset of sexual activity • History of PID or STI • Sexual intercourse at an early age • Alcohol or drug use • Having intercourse with a partner who has untreated urethritis • Recent insertion of an intrauterine contraceptive (IUC) • Nulliparity • Cigarette smoking • Recent termination of pregnancy • Lack of consistent condom use • Lack of contraceptive use • Douching • Prostitution (Shepherd, 2011) Assess the client for clinical manifestations of PID, keeping in mind that, because of the wide variety of clinical manifestations of PID, clinical diagnosis can be challenging. To reduce the risk of missed diagnosis, the CDC has established criteria to establish the diagnosis of PID. Minimal criteria (all must be present) are lower abdominal tenderness, adnexal tenderness, and cervical motion tenderness. Additional supportive criteria that support a diagnosis of PID are: • Abnormal cervical or vaginal mucopurulent discharge • Oral temperature above 101°F • Elevated erythrocyte sedimentation rate (inflammatory process)



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• Elevated C-reactive protein level (inflammatory process) • N. gonorrhoeae or C. trachomatis infection documented (causative bacterial organism) • White blood cells on saline vaginal smear • Prolonged or increased menstrual bleeding • Dysmenorrhea • Dysuria • Painful sexual intercourse • Nausea • Vomiting (CDC, 2012i)

Physical Examination and Laboratory and Diagnostic Tests Inspect the client for presence of fever (usually over 101°F) or vaginal discharge. Palpate the abdomen, noting tenderness over the uterus or ovaries. However, the only way to diagnose PID definitively is through an endometrial biopsy, transvaginal ultrasound, or laparoscopic examination.

Nursing Management If the woman with PID is hospitalized, maintain hydration via intravenous fluids if necessary and administer analgesics as needed for pain. Semi-Fowler’s positioning facilitates pelvic drainage. A key element to treatment of PID is education to prevent recurrence. Depending on the clinical setting (hospital or community clinic) where the nurse encounters the woman diagnosed with PID, a risk assessment should be done to ascertain what interventions are appropriate to prevent a recurrence. To gain the woman’s cooperation, explain the various diagnostic tests needed. Discuss the implications of PID and the risk factors for the infection; her sexual partner should be included if possible. Sexual counseling should include practicing safer sex, limiting the number of sexual partners, using barrier contraceptives consistently, avoiding vaginal douching, considering another contraceptive method if she has an IUC and has multiple

Teaching Guidelines 5.4 PREVENTING PELVIC INFLAMMATORY DISEASE • Advise sexually active girls and women to insist their partners use condoms. • Discourage routine vaginal douching, as this may lead to bacterial overgrowth. • Encourage regular sexually transmitted infection screening. • Emphasize the importance of having each sexual partner receive antibiotic treatment.

sexual partners, and completing the course of antibiotics prescribed (Harrison, 2011). Review the serious sequelae that may occur if the condition is not treated or if the woman does not comply with the treatment plan. Ask the woman to have her partner go for evaluation and treatment to prevent a repeat infection. Provide nonjudgmental support while stressing the importance of barrier contraceptive methods and follow-up care. Teaching Guidelines 5.4 gives further information related to PID prevention.

VACCINE-PREVENTABLE STIs Some STIs can be effectively prevented through preexposure vaccination. Vaccines are under development or are undergoing clinical trials for certain STIs, including HIV and HSV. However, the only vaccines currently available are for prevention of HAV, HBV, and HPV infection. Vaccination efforts focus largely on integrating the use of these available vaccines into STI prevention and treatment activities (CDC, 2011d).

Human Papillomavirus Human papillomavirus (HPV) is the most common viral infection in the United States (CDC, 2012j). Genital warts or condylomata (Greek for “warts”) are caused by HPV. Conservative estimates suggest that in the United States, approximately 20  million people have productive HPV infection, and 6.2  million Americans acquire it annually (CDC, 2012j). Clinical studies have confirmed that HPV is the cause of essentially all cases of cervical cancer, which is the fourth most common cancer in women in the United States, following lung, breast, and colorectal cancer (American Cancer Society [ACS], 2011). H ­ PV-mediated oncogenesis is responsible for up to 95% of cervical squamous cell carcinomas and nearly all preinvasive cervical neoplasms (­Gearhart & Randall, 2011). More than 30 types of HPV can ­infect the genital tract. HPV is most prevalent in young women between the ages of 20 and 24 years old, followed closely by the 15- to 19-year-old age group (Schuiling & Likis, 2013).

Take Note! The lifetime risk of HPV infection is estimated to be as high as 80% in sexually active people.

Nursing Assessment Nursing assessment of the woman with HPV involves a complete health history and assessment of clinical manifestations, physical examination, and laboratory and diagnostic testing.

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Health History and Clinical Manifestations Assess the client’s health history for risk factors for HPV, which include having multiple sex partners, age 15 to 25 years old, sex with a male who has had multiple sexual partners, and first intercourse at 16 or younger (Daley, 2011). Risk factors contributing to the development of cervical cancer include smoking, few or no screenings for cervical cancer, multiple sex partners, immunosuppressed state, long-term contraceptive use (more than 2  years), co-infection with another STI, pregnancy, nutritional deficiencies, and early onset of sexual activity (Schuiling & Likis, 2013). Assess the client for clinical manifestations of HPV. Most HPV infections are asymptomatic, unrecognized, or subclinical. Visible genital warts usually are caused by HPV types 6 or 11. In addition to the external genitalia, genital warts can occur on the cervix and in the vagina, urethra, anus, and mouth. Depending on the size and location, genital warts can be painful, friable, and pruritic, although most are typically asymptomatic (Fig. 5.8). The strains of HPV associated with genital warts are considered low risk for development of cervical cancer, but other HPV types (16, 18, 31, 33, and 35) have been strongly associated with cervical cancer (CDC, 2012j).

Physical Examination and Laboratory and Diagnostic Tests Clinically, visible warts are diagnosed by inspection. The warts are fleshy papules with a warty, granular surface. Lesions can grow very large during pregnancy, affecting

urination, defecation, mobility, and descent of the fetus (CDC, 2012j). Large lesions, which may resemble cauliflowers, exist in coalesced clusters and bleed easily. Serial Pap smears are performed for low-risk women. These regular Pap smears will detect the cellular changes associated with HPV. The FDA has recently approved an HPV test as a follow-up for women who have an ambiguous Pap test. In addition, this HPV test may be a helpful addition to the Pap test for general screening of women age 30 and over. The HPV test is a diagnostic test that can determine the specific HPV strain, which is useful in discriminating between low-risk and high-risk HPV types. A specimen for testing can be obtained with a fluid-phase collection system such as Thin Prep. The HPV test can identify 13 of the high-risk types of HPV associated with the development of cervical cancer and can detect high-risk types of HPV even before there are any conclusive visible changes to the cervical cells. If the test is positive for the high-risk types of HPV, the woman should be referred for colposcopy.

Upon physical examination, it is determined that Sandy has genital warts. The nurse finds out that Sandy engaged in high-risk behavior with a stranger she “hooked up” with recently at college. She couldn’t imagine that he would give her a STI because “he looked so clean-cut.” She wonders how she could possibly have genital warts. What ­information should be given to Sandy about STIs in general? What specific information about HPV should be stressed?

Genital warts on perineum

FIGURE 5.8 Genital warts. (Illustration provided by Anatomical Chart Co. Photograph from Sherwood L. Gorbach, John G. Bartlett, etal. Infectious Diseases. Philadelphia: Lippincott Williams & Wilkins, 2004.)



Therapeutic Management There is currently no medical treatment or cure for HPV. Instead, therapeutic management focuses heavily on prevention through the use of the HPV vaccine and education and on the treatment of lesions and warts caused by HPV. The FDA has approved two HPV vaccines to prevent cervical cancer: Cervarix and Gardasil. The CDC’s Advisory Committee on Immunization Practices (ACIP) has recommended the vaccine for routine administration to 11- and 12-year-old girls and boys. The ACIP also endorsed the use of a HPV vaccine for girls and boys as young as 9 and recommended that women between the ages of 13 and 26 receive the vaccination series, which consists of three injections over 6 months. Both are prophylactic HPV vaccines designed primarily for cervical cancer prevention. Cervarix is effective against HPV-16, -18, -31, -33 and -45, the five most common cancer-­causing types, including most causes of adenocarcinoma for which we cannot screen adequately. Gardasil is effective against HPV-16, -18, and -31, three common squamous cell cancer-causing types. In addition, Gardasil is effective against HPV-6 and -11, causes of genital warts and respiratory papillomatosis. The most important determinant of vaccine impact to reduce cervical cancer is its duration of efficacy. To date, Cervarix’s efficacy is proven for 6.4 years and Gardasil’s for 5 years (CDC, 2011e). Prophylactic HPV vaccines are safe, well tolerated, and highly efficacious in preventing persistent infections and cervical diseases associated with vaccineHPV types among young females. However, long-term efficacy and safety needs to be addressed in the future (National Cancer Institute 2012). The vaccine is administered intramuscularly in three separate 0.5-mL doses. The first dose may be given to any individual 9 to 26 years old prior to infection with HPV. The second dose is administered 2 months after the first, and the third dose is given 6 months after the initial dose. The deltoid region of the upper arm or anterolateral area of the thigh may be used. The most common vaccine side effects included pain, fainting, redness, and swelling at the injection site; fatigue; headache; muscle and joint aches; and gastrointestinal distress. Serious adverse events reported to the CDC include blood clots occurring in the heart, lungs, or legs; Guillain-Barre syndrome; and ,30 deaths. Most client profiles had risk factors that may have attributed to these adverse events and not to the vaccine alone (CDC, 2011e). The vaccine is given in a series of three injections over a 6-month period (CDC, 2011e). If the woman doesn’t receive primary prevention with the vaccine, then secondary prevention would focus on education about the importance of receiving regular Pap smears and, for women over 30, including an HPV test to determine whether the woman has a latent high-risk virus that could lead to precancerous ­cervical

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changes. Finally, treatment options for precancerous cervical lesions or genital warts caused by HPV are numerous and may include: • Topical trichloroacetic acid (TCA) 80% to 90% • Liquid nitrogen cryotherapy • Topical imiquimod 5% cream (Aldara) • Topical podophyllin 10% to 25% • Laser carbon dioxide vaporization • Client-applied Podofilox 0.5% solution or gel • Simple surgical excision • Loop electrosurgical excisional procedure (LEEP) • Intralesional interferon therapy (National Institute of Allergy and Infectious Diseases [NIAID], 2011a) The goal of treating genital warts is to remove the warts and induce wart-free periods for the client. Treatment of genital warts should be guided by the preference of the client and available resources. No single treatment has been found to be ideal for all clients, and most treatment modalities appear to have comparable efficacy. Because genital warts can proliferate and become friable during pregnancy, they should be removed using a local agent. A cesarean birth is not indicated solely to prevent transmission of HPV infection to the newborn, unless the pelvic outlet is obstructed by warts ­(Gearhart & Randall, 2011).

Nursing Management An HPV infection has many implications for the woman’s health, but most women are unaware of HPV and its role in cervical cancer. The average age of sexual debut is in early adolescence; therefore, it is important to target this population for use of the HPV/cervical cancer vaccine. Key nursing roles are teaching about prevention of HPV infection and client education and promotion of vaccines and screening tests in order to reduce the morbidity and mortality associated with cervical cancer caused by HPV infection. Teach all women that the only way to prevent HPV is to refrain from any genital contact with another person. Although the effect of condoms in preventing HPV infection is unknown, latex condom use has been associated with a lower rate of cervical cancer. Teach women about the link between HPV and cervical cancer. Explain that, in most cases, there are no signs or symptoms of infection with HPV. Strongly encourage all young women between 9 and 26 to consider getting ­Gardasil, the vaccine against HPV. For all women, promote the importance of obtaining regular Pap smears and, for women over 30, suggest an HPV test to rule out the presence of a latent high-risk strain of HPV. Education and counseling are important aspects of managing women with genital warts. Teach the woman that: • Even after genital warts are removed, HPV still remains and viral shedding will continue.

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• The likelihood of transmission to future partners and the duration of infectivity after treatment for genital warts are unknown. • The recurrence of genital warts within the first few months after treatment is common and usually indicates recurrence rather than reinfection (CDC, ­ 2012j).

Sandy is being treated for HPV and is anxious for her “things” to disappear and never return. What education is needed to prevent further transmission from Sandy to any future sexual partners?

Hepatitis A and B Hepatitis is an acute, systemic, viral infection that can be transmitted sexually. The viruses associated with hepatitis or inflammation of the liver are hepatitis A, B, C, D, E, and G. Hepatitis A (HAV) is spread via the gastrointestinal tract. It can be acquired by drinking polluted water, by eating uncooked shellfish from ­sewage-contaminated waters or food handled by a hepatitis carrier with poor hygiene, and from oral/anal sexual contact. Approximately 33% of the U.S. population has serologic evidence of prior hepatitis A infection; the rate increases directly with age (Matteucci & Schub, 2012). A person with hepatitis A can easily pass the disease to others within the same household. Hepatitis B (HBV) is transmitted through saliva, blood serum, semen, menstrual blood, and vaginal secretions. The incubation period from the time of exposure to onset of symptoms is 6 weeks to 6  months (CDC, 2012k). In the early 2000s, transmission among heterosexual partners accounted for 40% of infections, and transmission among men who have sex with men accounted for 20% of infections. The World Health Organization (WHO) estimates the prevalence of hepatitis B worldwide is 2 billion people, with about 350 million chronically infected with it. Worldwide, hepatitis B has the highest death rate of any STI except HIV (WHO, 2012). Risk factors for infection include having multiple sex partners, engaging in unprotected receptive anal intercourse, and having a history of other STIs (CDC, 2012k). The most effective means to prevent the transmission of hepatitis A or B is preexposure immunization. Vaccines are available for the prevention of HAV and HBV, both of which can be transmitted sexually. Every person seeking treatment for an STI should be considered a candidate for hepatitis B vaccination, and some individuals (e.g., men who have sex with men, and injection-drug users) should be considered for hepatitis A vaccination (CDC, 2012k).

Therapeutic Management Unlike other STIs, HBV and HAV are preventable through immunization. HAV is usually self-limiting and does not result in chronic infection. HBV can result in serious, permanent liver damage. Treatment is generally supportive. No specific treatment for acute HBV infection exists.

Nursing Assessment Assess the client for clinical manifestations of hepatitis A and B. Hepatitis A produces flulike symptoms with malaise, skin rashes, fatigue, anorexia, nausea, pruritus, fever, and upper right quadrant pain. Symptoms of hepatitis B are similar to those of hepatitis A, but with less fever and skin involvement. The diagnosis of hepatitis A cannot be made based on clinical manifestations alone and requires serologic testing. The presence of IgM ­antibody to HAV is diagnostic of acute HAV infection. Hepatitis B is detected by a blood test that looks for antibodies and proteins produced by the virus and is positively diagnosed by the presence of hepatitis B surface antibody (HBsAg) (Pyrsopoulos & Reddy, 2011).

Nursing Management Nurses should encourage all women to be screened for hepatitis when they have their annual Pap smear, or sooner if high-risk behavior is identified. Nurses should also encourage women to undergo HBV screening at their first prenatal visit and repeat screening in the last trimester for women with high-risk behaviors (Gilbert, 2011). Nurses can also explain that hepatitis B vaccine is given to all infants after birth in most hospitals. The vaccination consists of a series of three injections given within 6  months. The vaccine has been shown to be safe and well tolerated by most recipients (CDC, 2012k). Hepatitis A vaccine is strongly encouraged for children between 12 and 23 months; persons 1 year of age and older traveling to countries with a high prevalence of hepatitis A, such as Central or South America, Mexico, Asia, Africa, and eastern Europe; men who have sex with men; persons who use street drugs; and persons with chronic liver disease (CDC, 2012k). For others, hepatitis A vaccine series (two doses 6 months apart) may be started whenever a person is at risk of infection.

Hepatitis C Although HCV is not transmitted sexually, it deserves a brief mention here because injection-drug use by women places them at risk for it. Women at high risk include those with a history of injecting-drug use and those with a history of blood transfusion before 1992 (CDC, 2012m).



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The prevalence of HCV infection in pregnant women is approximately 1%. The majority of infected women are not aware they have HCV because they are not clinically ill. Perinatal transmission of HCV is relatively rare, except in women who are immunocompromised (HIV/ AIDS) (Mattson & Smith, 2011).

ECTOPARASITIC INFECTIONS Ectoparasites are a common cause of skin rash and pruritus throughout the world, affecting people of all ages, races, and socioeconomic groups. Overcrowding, delayed diagnosis and treatment, and poor public education contribute to the prevalence of ectoparasites in both industrial and nonindustrial nations. ­Approximately 300  million cases of ectoparasitic cases are reported worldwide each year (CDC, 2012l). These infections include infestations of scabies and pubic lice. Since these parasites are easily passed from one person to another during sexual intimacy, clients should be assessed for them when receiving care for other STIs. Scabies is an intensely pruritic dermatitis caused by a mite. The female mite burrows under the skin and deposits eggs, which hatch. The lesions start as a small papule that reddens, erodes, and sometimes crusts. Diagnosis is based on ­history and appearance of burrows in the webs of the fingers and the genitalia (Wells, Burgess, McNeilly, ­Huntley, & Nisbet, 2012). Aggressive infestation can occur in immunodeficient, debilitated, or malnourished people, but healthy people do not usually suffer sequelae. Clients with pediculosis pubis (pubic lice) usually seek treatment because of the pruritus, because of a rash brought on by skin irritation from scratching, or because they notice lice or nits in their pubic hair, axillary hair, abdominal and thigh hair, and sometimes in the eyebrows, eyelashes, and beards. Infestation is usually asymptomatic until after a week or so, when bites cause pruritus and secondary infections from scratching (­ Fig. 5.9). Diagnosis is based on history and the presence of nits (small, shiny,

FIGURE 5.9 Pubic lice. A small brown ­living crab louse is seen at the base of hairs (­ arrow). (From Goodheart, H. [2009]. G ­ oodheart’s photoguide of common skin disorders. ­Philadelphia: Lippincott Williams & Wilkins.)

yellow, oval, dewdrop-like eggs) ­affixed to hair shafts or lice (a yellowish, oval, wingless insect) (Kaplan, 2011). Treatment is directed at the infested area, using permethrin 1% lotion (Nix) and pyrethrin with piperonyl butoxide (Rid) which are FDA approved for treating head lice. Both are available as OTC preparations. Repeat treatment in 1 week is advised to eradicate eggs that may have hatched after treatment started (King & Brucker, 2011). Bedding and clothing should be washed in hot water to decontaminate it. Sexual partners should be treated also, as well as family members who live in close contact with the infected person. Nursing care of a woman infested with lice or scabies involves a three-tiered approach: eradicating the infestation with medication, removing nits, and preventing spread or recurrence by managing the environment. Over-the-counter products are safe for use and kill the active lice or mites. Nurses should provide education about these products (Teaching Guidelines 5.5). The nurse can follow these same guidelines to prevent the health care facility from becoming infested.

Teaching Guidelines 5.5 TREATING AND MINIMIZING THE SPREAD OF SCABIES AND PUBIC LICE • Use the medication according to the manufacturer’s instructions. • Remove nits with a fine-toothed nit comb. • Do not share any personal items with others or accept items from others. • Treat objects, clothing, and bedding and wash them in hot water. • Meticulously vacuum carpets to prevent a recurrence of infestation.

HUMAN IMMUNODEFICIENCY VIRUS (HIV) An estimated 1 million people in the United States currently live with HIV (NIAID, 2011c) and new cases of HIV infection have remained stable at about 50,000 annually since 2006 (CDC, 2011a). In terms of epidemiology, fatality rate, and its social, legal, ethical, and political aspects, HIV infection became a global public health crisis over 20 years ago and has generated more concern than any other infectious disease in modern medical history (Simms, 2011). To date, there is no cure for this fatal viral infection. The HIV virus is transmitted by intimate sexual contact, by sharing needles for intravenous drug use, from mother to fetus during pregnancy, or by transfusion of infected blood or blood products. Men who have sex

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with men represent the largest proportion of new infections, followed by men and women infected through heterosexual sex (CDC, 2011a). The number of women living with HIV infection worldwide is 15.7 million (all adults 33.4 million) (UNAIDS, 2012). About 10,000 new cases of HIV infection among women in the United States occur each year (CDC, 2011a). HIV infection disproportionately affects African American and Hispanic women .Together they represent less than 25% of all U.S. women, yet they account for more than 82% of HIV infection cases (CDC, 2011a). Women are particularly vulnerable to heterosexual transmission of HIV due to substantial mucosal exposure to seminal fluids. This biologic fact amplifies the risk of HIV transmission when coupled with the high prevalence of nonconsensual sex, sex without condoms, and the unknown and/or high-risk behaviors of their partners (NIAID, 2011b). Therefore, the face of HIV/AIDS is becoming the face of young women. That shift will ultimately exacerbate the incidence of HIV because women spread it not only through sex, but also through nursing and childbirth. AIDS is a breakdown in the immune function caused by HIV, a retrovirus. The infected person develops opportunistic infections or malignancies that become fatal. Progression from HIV infection to AIDS varies within individuals. HIV affects CD4 cells in two ways: by depleting them and by impairing the remaining ones. This invasion of CD4 cells results in a gradual loss of immune function. If nothing is done to stop this invasion of CD4 cells, HIV can destroy as many as 1  billion CD4 cells daily (Schuiling & Likis, 2013). Over 30 years (1981) have passed since HIV/AIDS began to affect our society. Since then, 1 million people have been infected by the virus, with AIDS being the fourth leading cause of death globally (CDC, 2012l). The morbidity and mortality of HIV continue to hold the ­attention of the medical community. While there has been a dramatic improvement in both morbidity and mortality with the use of antiretroviral therapy (ART), the incidence of HIV infection continues to be a public health challenge.

Take Note! Once the HIV infection has progressed to AIDS, the survival period is usually less than 2 years in untreated clients (Bennett & Gilroy, 2012). The fetal and neonatal effects of acquiring HIV through perinatal transmission can be devastating. If the HIV-infected infant goes untreated, progression to AIDS and eventual fatality will occur. An infected mother can transmit HIV infection to her newborn before or ­during birth and through breastfeeding. Current incidence of perinatal transmission is 612 per 100,000 infants (CDC, 2010c).

HIV and Adolescents As a typical function of development adolescents may view themselves as invincible, and thus delay seeking health care. They may be embarrassed or lack access to health care or may delay or refuse treatment if a diagnosis of HIV infection is made. Though the rates of HIV infection among adolescents have remained stable since 2006, the effects of HIV infection in this population continue to be of concern (CDC, 2011b). On average, the development of AIDS occurs about 11  years after infection, so most young adults with AIDS were infected during adolescence (Fahrner & Romano, 2010). Most HIV-infected adolescents are exposed to the virus through heterosexual or homosexual contact. The majority of HIV-infected adolescent males are infected through sex with other males, while female teenagers are mostly exposed through heterosexual contact. Injected drug use accounts for a small percentage of HIV infection among male and female adolescents. Similar to HIV infection in women, African American and Hispanic adolescents represent a disproportionate percentage of HIV infection among teenagers (CDC, 2011b).

Clinical Manifestations HIV infection undergoes three distinct phases—acute seroconversion, asymptomatic infection, and then progresses to AIDS. When a person is initially infected with HIV, he or she goes through an acute primary infection period for about 3 weeks. The HIV viral load drops rapidly because the host’s immune system works well to fight this initial infection. The onset of the acute primary infection occurs 2 to 6 weeks after exposure. Symptoms include fever, pharyngitis, rash, and myalgia. Most people do not associate this flulike condition with HIV infection. After initial exposure, there is a period of 3 to 12 months before seroconversion. The person is considered infectious during this time. After the acute phase, the infected person becomes asymptomatic, but the HIV virus begins to replicate. Even though there are no symptoms, the immune system runs down. A normal person has a CD4 T-cell count of 450 to 1,200 cells per microliter. When the CD4 T-cell count reaches 200 or less, the person has reached the stage of AIDS. The immune system begins a constant battle to fight this viral invasion, but over time it falls behind. A viral reservoir occurs in T cells that can store various stages of the virus. The onset and severity of the disease correlate directly with the viral load: the more HIV virus that is present, the worse the person will feel. As profound immunosuppression begins to occur, an opportunistic infection will occur, qualifying the person for the diagnosis of AIDS. The diagnosis is finally confirmed when the CD4 count is below 200. As of now, AIDS will eventually develop in everyone who is HIV-positive.



WHO (2012) now recommends earlier initiation of antiretroviral therapy (ART) for adults and adolescents, the delivery of more client-friendly antiretroviral drugs (ARVs), and prolonged use of ARVs to reduce the risk of mother-to-child transmission of HIV. ART should be started when the CD4 count reaches the 350 to 500 range. Also, for the first time, WHO (2012) recommends that HIV-positive mothers or their infants take ARVs while breastfeeding to prevent HIV transmission for up to 12 months after birth.

Diagnosis Screening for human immunodeficiency virus (HIV) infection is paramount, since infected individuals may remain asymptomatic for years while the infection progresses. Currently there are two categories of screening methods: rapid HIV tests and confirmatory tests. The rapid tests allow for screening at the point of care and offer quick results. The three rapid HIV tests that are FDA approved are OraQuick Advance HIV tests (whole blood used); Uni-Gold Recombigen HIV test (whole blood used); and Reveal Rapid HIV Antibody test (serum or plasma used). A positive result is followed up with one of two confirmatory tests: Western blot (WB) test or immunofluorescence assay (IFA) (Bayer & Oppenheimer, 2011). Quick tests for HIV produce results in 20 minutes and also lower the health care worker’s risk of occupational exposure by eliminating the need to draw blood. The CDC’s Advancing HIV Prevention initiative, launched in 2003, has made increased testing a national priority. The initiative calls for testing to be incorporated into all routine medical care and to be delivered in more nontraditional settings. Fewer than half of adults between the ages of 18 and 64 have ever had an HIV test, according to the CDC. The agency estimates that one fourth of the 1  million HIV-infected people in the United States do not know they are infected. This means they are not receiving treatment that can prolong their lives, and they may be unknowingly infecting others. In addition, even when people do get tested, one in three failed to return to the testing site to learn their results when there was a 2-week wait. The CDC hopes that the new “one-stop” approach to HIV testing changes that pattern. About 50,000 new HIV cases are reported each year in the United States, and that number has held steady for the past few years despite massive efforts in prevention education (CDC, 2012l). People who are infected with HIV but not aware of it are not able to take advantage of the therapies that can keep them healthy and extend their lives, nor do they have the knowledge to protect their sex or drug-use partners from becoming infected. Knowing whether one is positive or negative for HIV confers great benefits in healthy decision making.

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Rapid point of service HIV tests are becoming powerful screening tools in various health care settings because they offer the opportunity to not only screen for HIV, but also to educate the person regarding risk factors, and discuss their test results—all in one clinical visit. Most use a finger stick drop of blood or a swab of saliva taken from the mouth. Results are typically ready within 15 to 20 minutes. The CDC has specific protocols for confirmation of positive screening test results—­confirmation tests include the Western blot (WB) test or immunofluorescent assay (IFA) (Bayer & Oppenheimer, 2011). If the confirmation test (WB or IFA) is positive, the person is infected with HIV and is capable of transmitting the virus to others. HIV antibody is detectable in at least 95% of people within 3  months after infection (CDC, 2012l).

Therapeutic Management The goals of HIV drug therapy are to: • Decrease the HIV viral load below the level of detection • Restore the body’s ability to fight off pathogens • Improve the client’s quality of life • Reduce HIV morbidity and mortality (King & Brucker, 2011) Highly active antiretroviral therapy (HAART), which combines at least three antiretroviral drugs, has dramatically improved the prognosis of HIV/AIDS. Treatment with HAART should begin for any person with an AIDSdefining illness or with a history of a CD4 count less than 350 cells/mm (Kuritzkes, 2011). The current HAART standard is a triple combination therapy, but some clients may be given a fourth or fifth agent. Current therapy to prevent the transmission of HIV to the newborn includes a three-part regimen of having the mother take an oral antiretroviral agent at 14 to 34 weeks of gestation; it is continued throughout pregnancy. During labor, an antiretroviral agent is administered intravenously until delivery. An antiretroviral syrup is administered to the infant within 12 hours after birth. Dramatic new treatment advances with antiretroviral medications have turned a disease that used to be a death sentence into a chronic, manageable one for individuals who live in countries where antiretroviral therapy is available. Despite these advances in treatment, however, only a minority of HIV-positive Americans who take antiretroviral medications are receiving the full benefits because they are not adhering to the prescribed regimen. Successful antiretroviral therapy requires nearly perfect adherence to a complex medication regimen; less-thanperfect adherence leads to drug resistance (Maqutu & Zewotir, 2011). Adherence is difficult because of the complexity of the regimen and the lifelong duration of treatment.

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A typical antiretroviral regimen may consist of three or more medications taken twice daily. Adherence is made even more difficult because of the unpleasant side effects, such as nausea and diarrhea. Women in early pregnancy already experience these, and the antiretroviral medication only exacerbates them.

woman about changes she can make in her behavior to prevent spreading HIV to others, and refer her to appropriate community resources such as HIV medical care services, substance abuse, mental health services, and social services. See Nursing Care Plan 5.1: Overview for the Woman With HIV.

Nursing Management

Providing Education About Drug Therapy

Nurses can play a major role in caring for the ­HIV-positive woman by helping her accept the possibility of a s­hortened life span, cope with others’ reactions to a stigmatizing illness, and develop strategies to maintain her physical and emotional health. Educate the

The goal of antiretroviral therapy is to suppress viral replication so that the viral load becomes undetectable (below 400). This is done to preserve immune function and delay disease progression but is a challenge because of the side effects of nausea and vomiting, diarrhea, altered

NURSING CARE PLAN 5.1

Overview of the Woman Who is HIV-Positive Annie, a 28-year-old African American woman, is HIV-positive. She acquired HIV through unprotected sexual contact. She has been inconsistent in taking her antiretroviral medications and presents today stating she is tired and doesn’t feel well. NURSING DIAGNOSIS: Ineffective protection related to risk of infection secondary to inadequate ­immune system as manifested by client stating she has been inconsistent in taking her antiretroviral therapy medications. Outcome Identification and Evaluation

Client will remain free of opportunistic infections as evidenced by temperature within acceptable parameters and absence of signs and symptoms of opportunistic infections. Interventions: Minimizing the Risk of Opportunistic Infections

• Assess CD4 count and viral loads to determine disease progression (CD4 counts ,500/L and viral loads .10,000 copies/L 5 increased risk for opportunistic infections). • Assess complete blood count to identify presence of infection (.10,000 cells/mm3may indicate infection). • Assess oral cavity and mucous membranes for painful white patches in mouth to evaluate for possible fungal infection. • Teach client to monitor for general signs and symptoms of infections, such as fever, weakness, and fatigue, to ensure early identification. • Provide information explaining the importance of avoiding people with infections when possible to minimize risk of exposure to infections. • Teach importance of keeping appointments so her CD4 count and viral load can be monitored

to alert the health care provider about her ­immune system status. • Instruct her to reduce her exposure to infections via: • Meticulous handwashing • Thorough cooking of meats, eggs, and vegetables • Wearing shoes at all times, especially when outdoors • Encourage a balance of rest with activity throughout the day to prevent overexertion. • Stress importance of maintaining prescribed ­antiretroviral drug therapies to prevent disease progression and resistance. • If necessary, refer Annie to a nutritionist to help her understand what constitutes a well-balanced diet with supplements to promote health and ward off infection.



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NURSING CARE PLAN 5.1

Overview of the Woman Who is HIV-Positive

(continued)

NURSING DIAGNOSIS: Knowledge deficit related to HIV infection and possible complications. Outcome Identification and Evaluation

Client will demonstrate increased understanding of HIV infection as evidenced by verbalizing appropriate health care practices and adhering to measures to comply with therapy and ­reduce her risk of further exposure and reduce risk of disease progression. Interventions: Providing Client Education

• Assess her understanding of HIV and its treatment to provide a baseline for teaching. • Establish trust and be honest with Annie; encourage her to talk about her fears and the impact of the disease to provide an outlet for her concerns. Encourage her to discuss ­reasons for her noncompliance. • Provide a nonjudgmental, accessible, confidential, and culturally sensitive approach to promote Annie’s ­self-esteem and allow her to feel that she is a priority. • Explain measures, including safer sex practices and birth control options, to prevent disease transmission; ­determine her willingness to practice safer sex to protect others to ­determine further teaching needs. • Discuss the signs and symptoms of disease progression and potential opportunistic i­ nfections to promote early detection for prompt intervention. • Outline with the client the availability of community resources and make appropriate ­referrals as needed to provide additional education and support. • Encourage Annie to keep scheduled appointments to ensure follow-up and allow early ­detection of potential problems.

taste, anorexia, flatulence, constipation, headaches, anemia, and fatigue. Although not everyone experiences all of the side effects, the majority do have some of them. Current research hasn’t documented the long-term safety of exposure of the fetus to antiretroviral agents during pregnancy, but collection of data is ongoing. Help to reduce the development of drug resistance and thus treatment failure by identifying the barriers to adherence; identifying these barriers can help the woman to overcome them. Some of the common barriers exist because the woman: • Does not understand the link between drug resistance and nonadherence • Fears revealing her HIV status by being seen taking medication • Hasn’t adjusted emotionally to the HIV diagnosis • Doesn’t understand the dosing regimen or schedule • Experiences unpleasant side effects frequently • Feels anxious or depressed (Gilbert, 2011) Educate the woman about the prescribed drug therapy and stress that it is very important to take the regimen as prescribed. Offer suggestions about how to cope with anorexia, nausea, and vomiting by: • Separating the intake of food and fluids • Eating dry crackers upon arising

• Eating six small meals daily • Using high-protein supplements (Boost, Ensure) to provide quick and easy protein and calories • Eating “comfort foods,” which may appeal when other foods don’t

Promoting Compliance Remaining compliant with drug therapy is a huge challenge for many HIV-infected people. Compliance becomes difficult when the same pills that are supposed to thwart the disease are making the person sick. Nausea and diarrhea are just two of the possible side effects. It is often difficult to increase the client’s quality of life when so much oral medication is required. The combination medication therapy is challenging for many people, and staying compliant over a period of years is extremely difficult. Stress the importance of taking the prescribed antiretroviral drug therapies by explaining that they help prevent replication of the retroviruses and subsequent progression of the disease, as well as decreasing the risk of perinatal transmission of HIV. In addition, provide written materials describing diet, exercise, medications, and signs and symptoms of complications and opportunistic infections. Reinforce this information at each visit.

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Preventing HIV Infection The lack of information about HIV infection and AIDS causes great anxiety and fear of the unknown. It is vital to take a leadership role in educating the public about risky behaviors in the fight to control this disease. The core of HIV prevention is to abstain from sex until marriage, to be faithful, and to use condoms. This is all good advice for many women, but some simply do not have the economic and social power or choices or control over their lives to put that advice into practice. Recognize that fact, and address the factors that will give women more control over their lives by providing anticipatory guidance, giving ample opportunities to practice negotiation techniques and refusal skills in a safe environment, and encouraging the use of female condoms to protect against this deadly virus. Prevention is the key to reversing the current infection trends.

Providing Care During Pregnancy and Childbirth Voluntary counseling and HIV testing should be offered to all pregnant women as early in the pregnancy as possible to identify HIV-infected women so that treatment can be initiated early. Once a pregnant woman is identified as being HIV-positive, she should be informed about the risk for perinatal infection. The risk of perinatal transmission of HIV from an infected mother to her newborn is about 25%. This risk falls to about 2% if the mother receives antiretroviral therapy during pregnancy (Panel on Treatment of HIV-Infected Pregnant Women and Prevention of Perinatal Transmission, 2011). HIV can be spread to the infant through breastfeeding so when acceptable alternative infant formulas are readily available, HIV-infected mothers should be counseled to avoid breastfeeding and use formula instead. WHO (2010) recommendations indicate that transmission of HIV via breastmilk is decreased when the mother is undergoing antiretroviral therapy. In addition, the woman needs instructions on ways to enhance her immune system by following these guidelines during pregnancy: • Getting adequate sleep each night (7 to 9 hours) • Avoiding infections (e.g., staying out of crowds, handwashing) • Decreasing stress in her life • Consuming adequate protein and vitamins • Increasing her fluid intake to 2 liters daily to stay hydrated • Planning rest periods throughout the day to prevent fatigue Despite the dramatic reduction in perinatal transmission, hundreds of infants will be born infected with HIV. The birth of each infected infant is a missed prevention opportunity. To minimize perinatal HIV transmission,

identify HIV infection in women, preferably before pregnancy; provide information about disease prevention; and encourage HIV-infected women to follow the prescribed drug therapy.

Providing Appropriate Referrals The HIV-infected woman may have difficulty coping with the normal activities of daily living because she has less energy and decreased physical endurance. She may be overwhelmed by the financial burdens of medical and drug therapies and the emotional responses to a life-threatening condition, as well as concern about her infant’s future, if she is pregnant. A case management approach is needed to deal with the complexity of her needs during this time. Be an empathetic listener and make appropriate referrals for nutritional services, counseling, homemaker services, spiritual care, and local support groups. Many community-based organizations have developed programs to address the numerous issues regarding HIV/AIDS. The national AIDS hotline (1-800-342-AIDS) is a good resource. Table 5.4 provides a summary of perinatal effects of STIs during pregnancy.

PREVENTING SEXUALLY TRANSMITTED INFECTIONS Education about safer sex practices—and the resulting increase in the use of condoms—can play a vital role in reducing STI rates all over the world. Clearly, knowledge and prevention are the best defenses against STIs. The prevention and control of STIs is based on the following concepts (CDC, 2012a): 1. Education and counseling of people at risk about safer sexual behavior 2. Identification of asymptomatic infected people and of symptomatic people unlikely to seek diagnosis and treatment 3. Effective diagnosis and treatment of infected people 4. Evaluation, treatment, and counseling of sex partners of people who are infected with an STI 5. Preexposure vaccination of people at risk for vaccinepreventable STIs Nurses play an integral role in identifying and preventing STIs. They have a unique opportunity to educate the public about this serious public health issue by communicating the methods of transmission and symptoms associated with each condition, tracking the updated CDC treatment guidelines, and offering clients strategic preventive measures to reduce the spread of STIs. It is not easy to discuss STI prevention when globally we are failing at it. Knowledge exists on how to prevent every single route of transmission, but the incidence continues to climb. Challenges to prevention of



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TABLE 5.4

MATERNAL AND FETAL EFFECTS FROM STIs

STI

Maternal Effects

Fetal Effects

Candidiasis

Resistant to treatment during pregnancy Uncomfortable localized genital itching and discharge

Can acquire thrush in the mouth during birthing process if mother infected

Trichomoniasis

Has been implicated to cause PROM and preterm births

Risk of prematurity

Bacterial vaginosis

Increases risk for spontaneous abortion, PROM, chorioamnionitis, postpartum endometritis, and preterm labor

Risk of neonatal sepsis

Chlamydia

Postpartum endometritis, PROM, and preterm birth

Conjunctivitis, which can lead to blindness Low birth weight; and pneumonitis

Gonorrhea

Chorioamnionitis, preterm birth, PROM, intrauterine growth restriction (IUGR), postpartum sepsis

Eye infection gonococcal ophthalmia which can cause blindness

Genital herpes

Spontaneous abortion, intrauterine infection, preterm labor, PROM, intrauterine growth restriction (IUGR)

Birth anomalies; transplacental infection

Syphilis

Spontaneous abortion, preterm birth, stillbirth

Congenital syphilis: multisystem organ failure, structural damage; mental retardation

Human papillomavirus (HPV)

May cause dystocia if large lesions

None known

Hepatitis B

May cause preterm birth; can be transmitted to fetus if active in last trimester

Can become chronic carrier of hepatitis B which may lead to liver cancer or cirrhosis

HIV

Fatigue, nausea, weight loss

Transmission can occur transplacentally, during childbirth or through breast milk

Sources: Gilbert (2011); King & Brucker (2011); Gardner, Carter, Enzman-Hines, & Hernandez (2011); Mattson & Smith (2011). Gilbert, E. S. (2011). Manual of high-risk pregnancy and delivery (5th ed.). St. Louis: Mosby Elsevier; King, T. L., & Brucker, M. C. (2011). Pharmacology for women’s health. Sudbury, MA: Jones and Bartlett Publishers; Gardner, S. L., Carter, B. S., Enzman-Hines, M., & Hernandez, J. A. (2011). Merenstein & Gardner’s handbook of neonatal intensive care (7th ed.). St. Louis: Mosby Elsevier; Mattson, S., & Smith, J. E. (2011). Core curriculum for maternal-newborn nursing (4th ed.). St. Louis: Saunders Elsevier.

STIs include lack of resources and difficulty in changing the behaviors that contribute to their spread. Regardless of the challenging factors involved, nurses must continue to educate and to meet the needs of all women to promote their sexual health. Successful treatment and prevention of STIs is impossible without education. Successful teaching approaches include giving clear, accurate messages that are age-appropriate and culturally sensitive. Primary prevention strategies include education of all women, especially adolescents, regarding the risk of early sexual activity, the number of sexual partners, and STIs. Sexual abstinence is ideal but often not practiced;

therefore, the use of barrier contraception (condoms) should be encouraged (see Teaching Guidelines 5.1). Secondary prevention involves the need for annual pelvic examinations with Pap smears for all sexually active women, regardless of age. Many women with STIs are asymptomatic, so regular screening examinations are paramount for early detection. Understanding the relationship between poor socioeconomic conditions and poor patterns of sexual and reproductive self-care is significant in disease prevention and health promotion strategies. Every successful form of prevention requires a change in behavior. The nursing role in teaching and

194   U N I T 2   Women’s Health Throughout the Life Span BOX 5.3

SELECTED NURSING STRATEGIES TO PREVENT THE SPREAD OF STIs • Provide basic information about STI transmission. • Outline safer sexual behaviors for people at risk for STIs. • Refer clients to appropriate community resources to reduce risk. • Screen asymptomatic persons with STIs. • Identify barriers to STI testing and remove them. • Offer preexposure immunizations for vaccine-­ preventable STIs. • Respond honestly about testing results and options available. • Counsel and treat sexual partners of persons with STIs. • Educate school administrators, parents, and teens about STIs. • Support youth development activities to reduce sexual risk-taking. • Promote the use of barrier methods (condoms, diaphragms) to prevent the spread of STIs. • Assist clients to gain skills in negotiating safer sex. • Discuss reducing the number of sexual partners to reduce risk.

rendering quality health care is invaluable evidence that the key to reducing the spread of STIs is through behavioral change. Nurses working in these specialty areas have a responsibility to educate themselves, their clients, their families, and the community about STIs and to provide compassionate and supportive care to clients. Some strategies nurses can use to prevent the spread of STIs are detailed in Box 5.3.

Consider This

I was thinking of my carefree college days, when the

most important thing was having an active sorority life and meeting guys. I had been raised by very strict parents and was never allowed to date under their watch. Since I attended an out-of-state college, I figured that my parents’ outdated advice and rules no longer applied. Abruptly, my thoughts of the past were interrupted by the HIV counselor asking about my feelings concerning my positive diagnosis. What was there to say at this point? I had a lot of fun but never dreamed it would haunt me for the rest of my life, which was going to be shortened considerably now. I only wish I could turn back the hands of time and listen to my parents’ advice, which somehow doesn’t seem so outdated now.

Thoughts: All of us have thought back on our lives to better times and wondered how our lives would have changed if we had made better choices or gone down another path. It is a pity that we have only one chance to make good, sound decisions at times. What would you have changed in your life if given a second chance? Can you still make a change for the better now?

Behavior Modification Research validates that changing behaviors does result in a decrease in new STIs, but it must encompass all levels—governments, community organizations, schools, churches, parents, and individuals. Nurses can advocate for the development and implementation of educational initiatives to increase awareness of STIs ( Jeffers & DiBartolo, 2011). Education must address ways to prevent becoming infected, ways to prevent transmitting infection, symptoms of STIs, and treatment. At this point in the STI epidemic, nurses do not have time to debate the relative merits of prevention versus treatment: both are underused and underfunded, and one leads to the other. But being serious about prevention and focusing on the strategies outlined above will bring about a positive change on everyone’s part.

Contraception The spread of STIs could be prevented by access to safe, efficient, appropriate, modern contraception for everyone who wants it. Nurses can play an important role in helping women to identify their risk of STIs and to adopt preventive measures through the dual protection that contraceptives offer. Traditionally, family planning and STI services have been separate entities. Family planning services have addressed a woman’s need for contraception without considering her or her partner’s risk of STI; meanwhile, STI services have been heavily slanted toward men, ignoring the contraceptive needs of men and their partners. Many women are at significant risk for unintended pregnancy and STIs, yet with this separation of services, there is limited evaluation of whether they need dual protection—that is, concurrent protection from STIs and unintended pregnancy. This lack of integration of services represents a missed opportunity to identify many at-risk women and to offer them counseling on dual protection (Aitken, Carey, & Beagley, 2011). Nurses can expand their scopes in either setting by discussing dual protection by use of a male or female condom alone or by use of a condom along with a nonbarrier contraceptive. Because barrier methods are not the most effective means of fertility control, they have not been typically recommended as a method alone for dual



C h a p t e r 0 5  Sexually Transmitted Infections   195

protection. Unfortunately, the most effective pregnancy prevention methods—sterilization, hormonal methods, and intrauterine devices—do not protect against STIs. Dual-method use protects against STIs and pregnancy.

KEY CONCEPTS Avoiding risky sexual behaviors may preserve fertility and prevent chronic conditions later in life. An estimated 65 million people live with an incurable STI, and another 15 million are infected each year. The most reliable way to avoid transmission of STIs is to abstain from sexual intercourse (i.e., oral, vaginal, or anal sex) or to be in a long-term, mutually monogamous relationship with an uninfected partner. Barrier methods of contraception are recommended because they increase protection from contact with urethral discharge, mucosal secretions, and lesions of the cervix or penis. The high rate of asymptomatic transmission of STIs calls for teaching high-risk women the nature of transmission and how to recognize infections. The CDC and ACOG recommend that all women be offered group B streptococcal screening by rectovaginal culture at 35 to 37 weeks of gestation, and that colonized women be treated with intravenous antibiotics at the time of labor or ruptured membranes. Nurses should practice good handwashing techniques and follow standard precautions to protect themselves and their clients from STIs. Nurses are in an important position to promote the sexual health of all women. Nurses should make their clients and the community aware of the perinatal implications and lifelong sequelae of STIs.

References Aghaizu, A., Adams, E., Turner, K., Kerry, S., Hay, P., Simms, I., & ­Oakeshott, P. (2011). What is the cost of pelvic inflammatory disease and how much could be prevented by screening for Chlamydia trachomatis? Cost analysis of the prevention of pelvic infection (POPI) trial. Sexually Transmitted Infections, 87(4), 312–317. Aitken, R. J., Carey, A. J., & Beagley, K. W. (2011). Dual purpose contraceptives: Targeting fertility and sexually transmitted disease. Journal of Reproductive Immunology, 88(2), 228–232. Alexander, L. L., LaRosa, J. H., Bader, H., & Garfield, S. (2010). New dimensions in women’s health (5th ed.). Sudbury, MA: Jones and Bartlett Publishers. American Cancer Society. (2011). What women should know about cervical cancer and HPV. [Online] Available at http://www.cancer.org/ Cancer/CancerCauses/OtherCarcinogens/InfectiousAgents/HPV/ what-women-should-know-about-cervix-cancer-and-hpv

American Medical Association. (2012). Promoting teenage sexual health. [Online] Available at www.ama-assn.org/resources/doc/mss/ ph_sexualhealth_pres.pdf Badri, T., & Jennet, S. (2011). Rash associated with secondary syphilis. New England Journal of Medicine, 364(1), 71. Ball, H. H. (2011). Chlamydia and gonorrhea infection may be a­ ssociated with poor birth outcomes. Perspectives on Sexual & ­Reproductive Health, 43(2), 132–133. Barnack-Tavlaris, J.L., Reddy, D.M., & Ports, K. (2011). Psychological adjustment among women living with genital herpes. Journal of Health Psychology. 16(1), 12–21. Bayer, R., & Oppenheimer, G.M. (2011). Routine HIV screening—What counts in evidence-based policy? New England Journal of Medicine. 365(14), 1265–1268. Bennett, N. J., & Domachowske, J. (2011). Gonorrhea. eMedicine. ­Available at http://emedicine.medscape.com/article/964220-overview Bennett, N. J., & Gilroy, S. A. (2012). HIV disease. eMedicine. [Online] ­Available at http://emedicine.medscape.com/article/211316-overview Brocklehurst, P. (2012). Antibiotics for gonorrhoea in pregnancy. ­Cochrane Database of Systematic Reviews, (2), Art. No.: CD000098. DOI: 10.1002/14651858.CD000098. Campos-Outcalt, D. (2011). CDC update on gonorrhea: Expand treatment to limit resistance. Journal of Family Practice, 60(12), 736–740. CDC Ground Rounds (2011). Chlamydia prevention: Challenges and strategies for reducing disease burden and sequelae. MMWR. 60(12), 370–373. CDC (2011d). Vaccine-preventable STDs. Retrieved from http://www​ .cdc.gov/std/treatment/2010/vaccine.htm CDC (2011e). HPV vaccine information for clinicians–Fact sheet. Retrieved from http://www.cdc.gov/std/hpv/STDFact-HPV-vaccine-hcp. htm CDC (2012m). Hepatitis C information for health professionals. Retrieved from http://www.cdc.gov/hepatitis/HCV/HCVfaq.htm Centers for Disease Control and Prevention (2010a). Sexually transmitted diseases treatment guidelines, 2010. MMWR, 59(RR-12), 1–116. Retrieved June 19, 2011, from http://www.cdc.gov/std/treatment/2010/STD-Treatment-2010-RR5912.pdf –—. (2010b). Male latex condoms and sexually transmitted diseases. Condom fact sheet in brief. Retrieved May 4, 2010, from http://www .cdc.gov/condomeffectiveness/brief.html –—. (2010c). Racial/ethnic disparities among children with diagnoses of perinatal HIV infections–34 states. MMWR: Morbidity & Mortality Weekly Report, 59(4), 97–99. –—. (2011a). Estimates of new HIV infections in the United States, 2006-2009. Retrieved February 25, 2012, from http://www.cdc.gov/ nchhstp/newsroom/docs/HIV-Infections-2006-2009.pdf. –—. (2011b). HIV surveillance in adolescents and young adults ­[PowerPoint slides]. Retrieved February 25, 2012, from http://www.cdc .gov/hiv/topics/surveillance/resources/slides/adolescents/index.htm. –—. (2011c). Sexually transmitted disease surveillance 2010. U.S. ­Department of Health and Human Services: Atlanta, GA. –—. (2012a). Sexually transmitted diseases. [Online] Available at http://www.cdc.gov/std/ –—. (2012b). Genital vulvovaginitis candidiasis. [Online] Available at http://www.cdc.gov/fungal/Candidiasis/genital/ –—. (2012c). Trichomoniasis: CDC fact sheet. [Online] Available at http://www.cdc.gov/std/trichomonas/STDFact-Trichomoniasis.htm –—. (2012d). Bacterial vaginosis: CDC fact sheet. [Online] Available at http://www.cdc.gov/std/bv/STDFact-Bacterial-Vaginosis.htm –—. (2012e). Chlamydia: CDC fact sheet. [Online] Available at http:// www.cdc.gov/std/chlamydia/STDFact-Chlamydia.htm –—. (2012f). Gonorrhea: CDC fact sheet. [Online] Available at http:// www.cdc.gov/std/gonorrhea/STDFact-gonorrhea.htm –—. (2012g). Genital herpes: CDC fact sheet. [Online] Available at http://www.cdc.gov/std/Herpes/STDFact-Herpes.htm –—. (2012h). Syphilis: CDC fact sheet. [Online] Available at http://www .cdc.gov/std/syphilis/stdfact-syphilis.htm –—. (2012i). Pelvic inflammatory disease: CDC fact sheet. [Online] Available at http://www.cdc.gov/std/PID/STDFact-PID.htm –—. (2012j). Human papillomavirus: CDC fact sheet. [Online] Available at http://www.cdc.gov/std/HPV/STDFact-HPV.htm –—. (2012k). Vaccine-preventable STDs. [Online] Available at http:// www.cdc.gov/std/treatment/2010/vaccine.htm#a2

196   U N I T 2   Women’s Health Throughout the Life Span –—. (2012l). HIV/AIDS basic statistics. [Online] Available at http://www .cdc.gov/hiv/topics/surveillance/basic.htm#hivest Daley, A. (2011). Providing adolescent-friendly HPV education. Nurse Practitioner, 36(11), 35–40. Euerle, B., Chandrasekar, P. H., Diaz, M. M. et al. (2012) Syphilis. eMedicine. [Online] Available at http://emedicine.medscape.com/ article/229461-overview Expert Working Group on the Canadian Guidelines for Sexually Transmitted Infections. (2008). Canadian guidelines on sexually transmitted infections. Ottawa, ON: Public Health Agency of Canada. Fahrner, R., & Romano, S. (2010). HIV infection and AIDS. In P. J. Allen, J. A. Vessey, and N. A. Schapiro (eds.), Primary care of the child with a chronic condition (5th ed.). St. Louis: Mosby. Follett, T., & Clarke, D. (2011). Resurgence of congenital syphilis: ­Diagnosis and treatment. Neonatal Network, 30(5), 320–328. Gearhart, P. A., & Randall, T. C. (2011). Human papillomavirus. eMedicine. Available at http://emedicine.medscape.com/article/219110-overview Gilbert, E. S. (2011). Manual of high-risk pregnancy and delivery (5th ed.). St. Louis: Mosby Elsevier. Gülmezoglu A. M., & Azhar, M. (2011). Interventions for trichomoniasis in pregnancy. Cochrane Database of Systematic Reviews 2011, Issue 5. Art. No.: CD000220. DOI: 10.1002/14651858.CD000220. Guttmacher Institute. (2012). Facts on American teens’ sexual and reproductive health. [Online] Available at http://www.guttmacher.org/ pubs/FB-ATSRH.html Guttmacher Institute (2012). Facts on American teens sexual and reproductive health. Retrieved from http://www.guttmacher.org/pubs/ FB-ATSRH.html Harrison, M. (2011). Pelvic inflammatory disease. Pulse, 71(24), 17–18. Jaiyeoba, O., Lazenby, G., & Soper, D. (2011). Recommendations and rationale for the treatment of pelvic inflammatory disease. Expert Review of Anti-Infective Therapy, 9(1), 61–70. Jeffers, L. A., & DiBartolo, M. C. (2011). Raising health care provider awareness of sexually transmitted disease in patients over age 50. MEDSURG Nursing, 20(6), 285–290. Kaplan, D. W. (2011). Lice in the pubic area. CRS - Adult Health A ­ dvisor, 1. King, T. L. & Brucker, M. C. (2011). Pharmacology for women’s health. Sudbury, MA: Jones and Bartlett Publishers. Kuritzkes, D. (2011). HAART for HIV-1 infection: Zeroing in on when to start: Comment on “Timing of HAART initiation and clinical outcomes in human immunodeficiency virus type 1 seroconverters.” Archives of Internal Medicine, 171(17), 1569–1570. Maqutu, D., & Zewotir, T. (2011). Optimal HAART adherence over time and time interval between successive visits: their association and determinants. AIDS Care, 23(11), 1417–1424. March of Dimes. (2011). Sexually transmitted infections. Retrieved June 12, 2012, from http://www.marchofdimes.com/pregnancy/ complications_stis.html Mark, H., Lucea, M., Nanda, J., Farley, J., & Gilbert, L. (2011). Genital herpes testing among persons living with HIV. The Journal of The Association of Nurses in AIDS Care: JANAC, 22(5), 354–361. Matteucci, R., & Schub, T. (2012). Hepatitis A. [Online] Available at CINAHL Plus with Full Text, Ipswich, MA. Mattson, S., & Smith, J.E. (2011) Core curriculum for maternal-newborn nursing. (4th ed.), St. Louis, MO: Saunders Elsevier. Mehring, P. M. (2009). Sexually transmitted infections. In C. M. Porth and G. Matfin, Pathophysiology: Concepts of altered health states (8th ed., chap. 47, pp. 1167–1180). Philadelphia: Wolters Kluwer Health, Lippincott Williams & Wilkins. National Institute of Allergy and Infectious Diseases (NIAID). (2011a). HIV/AIDS. Retrieved February 25, 2012, from http://www.niaid.nih .gov/topics/hivaids/Pages/Default.aspx –—. (2011b). Human papillomavirus (HPV) and genital warts. [Online] Available at http://www.niaid.nih.gov/topics/genitalwarts/pages/ default.aspx

–—. (2011c). Understanding HIV/AIDS. [Online] Available at http:// www.niaid.nih.gov/TOPICS/HIVAIDS/UNDERSTANDING/Pages/ Default.aspx National Cancer Institute [NCI] (2012). Human papillomavirus (HPV) vaccines. REtrieved from http://www.cancer.gov/cancertopics/ factsheet/prevention/HPV-vaccine National Institute of Allergy and Infectious Diseases [NIAID] (2012). Genital herpes. Retrieved from http://www.niaid.nih.gov/topics/ genitalherpes/Pages/default.aspx Panel on Treatment of HIV-Infected Pregnant Women and Prevention of Perinatal Transmission. (2011). Recommendation for use of antiretroviral drugs in pregnant HIV-1-infected women for maternal health and interventions to reduce perinatal HIV transmission in the United States. Retrieved February 25, 2012, from http://www .aidsinfo.nih.gov/ContentFiles/PerinatalGL.pdf Pyrsopoulos, N. T., & Reddy, K. R. (2011). Hepatitis B. eMedicine. [Online] Available at http://emedicine.medscape.com/ article/177632-overview Rexroth, K., Hare, K., & Kan, V. (2011). Rapid oral HIV screening: E ­ xpectations revisited. Journal of Acquired Immune Deficiency ­Syndromes (1999), 56(2), e59–e60. Salvaggio, M. R., Lutwick, L. I., & Kumar, S. (2012). Herpes simplex. eMedicine. [Online] Available at http://emedicine.medscape.com/ article/218580-overview Schuiling, K. D., & Likis, F. E. (2013). Women’s gynecologic health (2nd ed.). Burlington, MA: Jones & Bartlett Learning. Shepherd, S. M. (2011). Pelvic inflammatory disease. e­ Medicine. [Online] Available at http://emedicine.medscape.com/article/256448-overview Simms, C. C. (2011). The HIV/AIDS crisis and the right to health. ­International Journal of Clinical Practice, 65(3), 233–236. Soleymani majd, H., Ismail, L., & Currie, I. (2011). GPs should be v­ igilant for pelvic inflammatory disease. The Practitioner, 255(1738), 15–18. Stamm, C. A., Mirand, R. H., & Mcgregor, J. A. (2011). An evidencebased approach to managing common STIs in adolescents. Contemporary OB/GYN, 56(9), 43–50. Struble, K., & Jackson, R.L. (2012) Chlamydia genitourinary infections. eMedicine. Retrieved from http://emedicine.medscape.com/ article/214823-overview Turner, D. (2012). Pelvic inflammatory disease: A continuing challenge. American Journal for Nurse Practitioners, 16(1/2), 20–23. UNAIDS (2012) Eliminating gender inequalities. Retrieved from http://www​ .unaids.org/en/targetsandcommitments/eliminatinggenderinequalities/ U.S. Department of Health and Human Services. (2010). Healthy People 2020. [Online] Available at http://www.healthypeople.gov/2020/ topicsobjectives2020/ Walker, C.K. & Sweet, R.L. (2011) Gonorrhea infection in women: Prevalence, effects, screening and management. International Journal of Women’s Health. 3; 197–206. Wells, B., Burgess, S., McNeilly, T., Huntley, J., & Nisbet, A. (2012). Recent developments in the diagnosis of ectoparasite infections and disease through a better understanding of parasite biology and host responses. Molecular and Cellular Probes, 26(1), 47–53 WHO (2012) Guidelines: HIV. Retrieved from http://www.who.int/hiv/ pub/guidelines/en/ World Health Organization. (2010). Guidelines on HIV and infant feeding - 2010. Principles and recommendations for infant feeding in the context of HIV and a summary of evidence. Retrieved February 25, 2012, from http://whqlibdoc.who.int/publications/2010/9789241599535_ eng.pdf –—. (2012). Hepatitis B fact sheet. [Online] Available at http://www .who.int/mediacentre/factsheets/fs204/en/ Zuppa, A., D’Andrea, V., Catenazzi, P., Scorrano, A., & Romagnoli, C. (2011). Ophthalmia neonatorum: What kind of prophylaxis? Journal of Maternal-Fetal & Neonatal Medicine, 24(6), 769–773.

CHAPTER W O R K S H E E T MULTIPLE-CHOICE QUESTIONS 1. Which of the following contraceptive methods offers protection against sexually transmitted infections (STIs)? a. Oral contraceptives b. Withdrawal c. Latex condom d. Intrauterine contraceptive (IUC) 2. In teaching about HIV transmission, the nurse explains that the virus cannot be transmitted by: a. Shaking hands b. Sharing drug needles c. Sexual intercourse d. Breastfeeding 3. A woman with HPV is likely to present with which nursing assessment finding? a. Profuse, pus-filled vaginal discharge b. Clusters of genital warts c. Single painless ulcer d. Multiple vesicles on genitalia 4. The nurse’s discharge teaching plan for the woman with PID should reinforce which of the following potentially life-threatening complications? a. Involuntary infertility b. Chronic pelvic pain c. Depression d. Ectopic pregnancy 5. To confirm a finding of primary syphilis, the nurse would observe which of the following on the external genitalia? a. A highly variable skin rash b. A yellow-green vaginal discharge c. A nontender, indurated ulcer d. A localized gumma formation CRITICAL THINKING EXERCISE 1. Sally, age 17, comes to the teen clinic saying that she is in pain and has some “crud” between her legs. The nurse takes her into the examining room and questions

her about her symptoms. Sally states she had numerous genital bumps that had been filled with fluid, then ruptured and turned into ulcers with crusts. In addition, she has pain on urination and overall body pain. Sally says she had unprotected sex with several men when she was drunk at a party a few weeks back, but she thought they were “clean.” a. What STI would the nurse suspect? b. The nurse should give immediate consideration to which of Sally’s complaints? c. What should be the goal of the nurse in teaching Sally about STIs? STUDY ACTIVITIES 1. Select a website at the end of the chapter to explore. Educate yourself about one specific STI thoroughly and share your expertise with your clinical group. 2. Contact your local health department and request current statistics regarding three STIs. Ask them to compare the current number of cases reported to last year’s. Are they less or more? What may be some of the reasons for the change in the number of cases reported? 3. Request permission to attend a local STI clinic to shadow a nurse for a few hours. Describe the nurse’s counseling role with clients and what specific information is emphasized to clients. 4. Two common STIs that appear together and commonly are treated together regardless of identification of the secondary one are __________________ and _______________________. 5. Genital warts can be treated with which of the following? Select all that apply. a. Penicillin b. Podophyllin c. Imiquimod d. Cryotherapy e. Antiretroviral therapy f. Acyclovir

197

6 KEY TERMS benign breast disorder breast cancer breast-conserving surgery breast selfexamination carcinoma chemotherapy duct ectasia endocrine therapy fibroadenomas fibrocystic breast changes mammography mastitis modified radical mastectomy simple mastectomy

Disorders of the Breasts Learning Objectives Upon completion of the chapter, you will be able to: 1. Define the key terms used in this chapter. 2. Identify the incidence, risk factors, screening methods, and treatment modalities for benign breast conditions. 3. Outline preventive strategies for breast cancer through lifestyle changes and health screening. 4. Analyze the incidence, risk factors, treatment modalities, and nursing considerations related to breast cancer. 5. Develop an educational plan to teach breast self-examination to a group of high-risk women.

Nancy hasn’t been able to sleep well since she felt the lump in her left breast over a month ago, just after her 60th ­birthday. She knows she is at high risk because her mother died of breast cancer, but she can’t bring herself to have it checked out.

WOW

Words of Wisdom

Focus on reducing fear, anxiety, pain, and aloneness in all women diagnosed with a breast disorder.



C h a p t e r 0 6   Disorders of the Breasts    199

The female breast is closely linked to womanhood in American culture. Women’s breasts act as physical markers for transitions from one stage of life to another, and although the primary function of the breasts is lactation, they are perceived as a symbol of beauty and sexuality. This chapter discusses assessments, screening procedures, and management of specific benign and malignant breast disorders. Nurses play a key role in helping women maintain breast health by providing education and screening. A good working knowledge of early detection techniques, diagnosis, and treatment options is essential.

BENIGN BREAST DISORDERS A benign breast disorder is any noncancerous breast abnormality. Though not life threatening, benign disorders can cause pain and discomfort, and they account for a large number of visits to primary care providers. Depending on the type of benign breast disorder, treatment might or might not be necessary. Although these disorders are benign, the emotional trauma women experience is phenomenal. Fear, anxiety, disbelief, helplessness, and depression are just a few of the reactions that a woman may have when she discovers a lump in her breast. Many women believe that all lumps are cancerous, but actually more than 80% of the lumps discovered are benign and need no treatment (Alexander, LaRosa, Bader, & Garfield, 2010). Patience, support, and education are essential components of nursing care. The most commonly encountered benign breast disorders in women include fibrocystic breasts,

fibroadenomas, and mastitis. Although these breast disorders are considered benign, fibrocystic breasts carry a cancer risk, with prolific masses and hyperplastic changes occurring within the breasts. Generally speaking, fibroadenomas and mastitis carry little cancer risk (Bope & Kellerman, 2012). Table 6.1 summarizes benign breast conditions.

Fibrocystic Breast Changes Fibrocystic breast changes, also known as benign breast disease (BBD), represent a variety of changes in the glandular and structural tissues of the breast. Because this condition affects 50% to 60% of all women at some point, it is more accurately defined as a “change” rather than a “disease.” The cause of fibrocystic changes is related to the way breast tissue responds to monthly levels of estrogen and progesterone. During the menstrual cycle, hormonal stimulation of the breast tissue causes the glands and ducts to enlarge and swell. One or both breasts can be involved, and any part of the breast can become tender (Kiyak, Asik, & Yazgan, 2011). Fibrocystic changes do not increase the risk of breast cancer for most women except when the breast biopsy shows “atypia” or abnormal breast cells. The cause for concern for many women with fibrocystic changes is that breast examinations and mammography become more difficult to interpret with multiple cysts present, and early cancerous lesions may occasionally be overlooked (American Cancer Society [ACS], 2011g). Fibrocystic breast changes are most common in women between the ages of 20 and 50. The condition

TABLE 6.1

SUMMARY OF BENIGN BREAST DISORDERS

Breast Condition

Nipple Discharge

Fibrocystic breast changes

Site

Characteristics/ Age of Client

+ or −

Bilateral; upper outer quadrant

Round, smooth Several lesions Cyclic, palpable 30–50 yrs old

+

Aspiration and biopsy . Limit caffeine; ibuprofen; supportive bra

Fibroadenomas

–

Unilateral; nipple area or upper outer quadrant

Round, firm, movable Palpable, rubbery Well delineated Single lesion 15–30 yrs old

–

Mammogram “Watchful waiting” Aspiration and biopsy Surgical excision

Mastitis

–

Unilateral; outer quadrant

Wedge shaped Warmth, redness Swelling Nipple cracked Breast engorged

+

Antibiotics Warm shower Supportive bra Breast-feeding Increase fluids

Tenderness

Diagnosis & Treatment

Adapted from Alexander, L. L., LaRosa, J. H., Bader, H., & Garfield, S. (2010). New dimensions in women’s health (5th ed.). Sudbury, MA: Jones & Bartlett; American Cancer Society [ACS]. (2011g). Non-cancerous breast conditions. Retrieved from http://www.cancer.org/Healthy/FindCancerEarly/ WomensHealth/Non-CancerousBreastConditions/non-cancerous-breast-conditions-fibrocystic-changes; Blackburn, S. T. (2012). Maternal, fetal & ­neonatal physiology (4th ed.). St. Louis, MO: Saunders Elsevier; and Bope, E. T., & Kellerman, R. D. (2012). Conn’s current therapy 2012. Philadelphia, PA: Saunders Elsevier.

200   U N I T 2   Women’s Health Throughout the Life Span

is rare in postmenopausal women not taking hormone replacement therapy. According to the ACS (2011g), fibrocystic breast changes affect at least half of all women at some point in their lives and are the most common breast disorder today.

Therapeutic Management Management of the symptoms of fibrocystic breast changes begins with self-care. In severe cases drugs, including bromocriptine, tamoxifen, or danazol, can be used to reduce the influence of estrogen on breast tissue. However, several undesirable side effects, including masculinization, have been documented. Aspiration or surgical removal of breast lumps will reduce pain and swelling by removing the space-occupying mass.

Nursing Assessment Nursing assessment consists of a health history, physical examination, and laboratory and diagnostic tests.

Health History Ask the woman about common clinical manifestations, which include lumpy, tender breasts, particularly during the week before menses. Changes in breast tissue produce pain by nerve irritation from edema in connective tissue and by fibrosis from nerve pinching. The pain is cyclic and frequently dissipates after the onset of menses. The pain is described as a dull, aching feeling of fullness. Masses or nodularities usually appear in both breasts and are often found in the upper outer quadrants. Some women also experience spontaneous clear to yellow nipple discharge when the breast is squeezed or manipulated.

Physical Examination It is best to examine a woman’s breast a week after menses, when swelling has subsided. The breast exam is performed using the Triple Touch Method in which the health care provider uses the pads of the middle three fingers and makes dime-sized overlapping circles to feel the breast tissue with three levels of pressure: light, medium, and firm (Dunn & Tan, 2011). Observe the breasts for fibrosis, or thickening of the normal breast tissues, which occurs in the early stages. Cysts form in the later stages and feel like multiple, smooth, well-delineated tiny pebbles or bumpy oatmeal under the skin (Fig.  6.1). On physical examination of the breasts, a few characteristics might be helpful in differentiating a cyst from a cancerous lesion. Cancerous lesions typically are fixed and painless and may cause skin retraction (pulling). Cysts tend to be mobile and tender and do not cause skin retraction in the surrounding tissue.

Laboratory and Diagnostic Tests Mammography can be helpful in distinguishing fibrocystic changes from breast cancer. Ultrasound is a useful adjunct to mammography for breast evaluation because it helps to differentiate a cystic mass from a solid one ­(Slanetz, Shieh-Pei, & Mendel, 2011). Ultrasound produces images of the breasts by sending sound waves through a gel applied to the breasts. Fine-needle aspiration biopsy can also be done to differentiate a solid tumor, cyst, or malignancy. A fine-needle aspiration biopsy uses a thin needle guided by ultrasound to the mass. In a method called stereotactic needle biopsy, a computer maps the exact location of the mass using mammograms taken from two angles, and the map is used to guide the needle.

Nursing Management A nurse caring for a woman with fibrocystic breast changes can teach her about the condition, provide tips for self-care (Teaching Guidelines 6.1), suggest lifestyle changes, and demonstrate how to perform monthly breast self-examination after her menses to monitor the

Teaching Guidelines 6.1 RELIEVING SYMPTOMS OF FIBROCYSTIC BREAST CHANGES • Wear an extra-supportive bra to prevent undue strain on the ligaments of the breasts to reduce discomfort. • Take oral contraceptives, as recommended by a health care practitioner, to stabilize the monthly hormonal levels. • Eat a low-fat diet rich in fruits, vegetables, and grains to maintain a healthy nutritional lifestyle and ideal weight. • Apply heat to the breasts to help reduce pain via vasodilation of vessels. • Take diuretics, as recommended by a health care practitioner, to counteract fluid retention and swelling of the breasts. • Reduce salt intake to reduce fluid retention and swelling in the breasts. • Take OTC medications, such as aspirin or ibuprofen (Motrin, Advil, Nuprin), to reduce inflammation and discomfort. • Use thiamine and vitamin E therapy. This has been found helpful for some women, but research has failed to demonstrate a direct benefit from either therapy. • Take medications as prescribed (e.g., bromocriptine, tamoxifen, or danazol). • Discuss the possibility of aspiration or surgical removal of breast lumps with a health care practitioner.



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Dense fibrous tissue

Cyst

Pectoralis muscle

Pectoralis muscle

Fat

Fat

Normal lobules

Normal lobules

A

B

Skin

Cysts

Epithelial hyperplasia

Small, cystically dilated breast duct

D

C

Dense fibrous tissue

Normal breast fat

Fibrous tissue with a few inflammatory cells

FIGURE 6.1 (A) Fibrocystic breast changes. (B) Breast cysts. (C) This gross study shows that most of the abnormal tissue is fibrous. Cysts are relatively inconspicuous in this example. (D) The microscopic study shows dense fibrous tissue containing dilated ducts lined by hyperplastic epithelium. (Images A & B are from The Anatomical Chart Company. [2006]. Atlas of Pathophysiology. Springhouse, PA: Springhouse Corporation. Images C & D courtesy of McConnell, Thomas H. [2007]. The Nature of Disease Pathology for the Health Professions, Philadelphia, PA: Lippincott Williams & Wilkins.)

changes. Nursing Care Plan 6.1 presents a plan of care for a woman with fibrocystic breast changes.

Fibroadenomas Fibroadenomas are common benign solid breast ­tumors that occur in about 25% of all women and

account for up to half of all breast biopsies. They are the most common mass in women aged 15 to 35 years (Aliotta & Schaeffer, 2010). They are considered hyperplastic lesions associated with an aberration of normal ­ development and involution rather than a neoplasm. ­Fibroadenomas can be stimulated by external estrogen, progesterone, lactation, and pregnancy (Bope & Kellerman, 2012). They are composed

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of both fibrous and glandular tissue that feels round or oval, firm, rubbery and smooth, and is mobile and may be tender. They are usually unilateral, but may present in both breasts (Alexander et al., 2010). Giant fibroadenomas account for approximately 10% of cases. These masses are frequently larger than 5  cm and occur most often in pregnant or lactating women. These large lesions may regress in size once hormonal stimulation subsides (Hackley, Kriebs, & ­Rousseau, 2010). Fibroadenomas are rarely associated with cancer.

Rubbery, circumscribed, freely movable benign tumor

Therapeutic Management Treatment may include a period of “watchful waiting” because many fibroadenomas stop growing or shrink on their own without any treatment. Other growths may need to be surgically removed if they do not regress or if they remain unchanged. Cryoablation, an alternative to surgery, can also be used to remove a tumor. In this procedure, extremely cold gas is piped into the tumor using ultrasound guidance. The tumor freezes and dies. The current trend is toward a more conservative approach to treatment after careful evaluation and continued monitoring.

A

Nursing Assessment Ask the woman about clinical manifestations of fibroadenomas. These lumps are felt as firm, rubbery, wellcircumscribed, freely mobile nodules that might or might not be tender when palpated. Breast fibroadenomas are usually detected incidentally during clinical or self-examinations and are usually located in the upper outer quadrant of the breast; more than one may be present (Fig. 6.2). Several other breast lesions have similar characteristics, so every woman with a breast mass should be evaluated to exclude cancer. A clinical breast examination by a health care professional is critical. In addition, diagnostic studies include imaging studies (mammography, ultrasound, or both) and some form of biopsy, most often a fine-needle aspiration, core needle biopsy, or stereotactic needle biopsy. The core needle biopsy removes a small cylinder of tissue from the breast mass, more than the fine-needle aspiration biopsy. If additional tissue needs to be evaluated, the advanced breast biopsy instrument (ABBI) is used. This instrument removes a larger cylinder of tissue for examination by using a rotating circular knife. The ABBI procedure removes more tissue than any of the other methods except a surgical biopsy (ACS, 2011f).

B FIGURE 6.2 (A) Fibroadenoma. (Asset provided by Anatomical Chart Co.) (B) Spot compression view of a smoothly marinated mass proven to represent a fibroadenoma. Ultrasonography demonstrated a solid mass.



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NURSING CARE PLAN 6.1

Overview of The Woman With Fibrocystic Breast Changes Sheree Rollins is a 37-year-old woman who comes to the clinic for her routine checkup. During the examination, she says, “Sometimes my breasts feel so heavy and they ache a lot. I noticed a couple of lumpy areas in my breast last week just before I got my period. Is this normal? Now they feel like they’re almost gone. Should I be worried?” Clinical breast examination reveals two small (pea-sized), mobile, slightly tender nodules in each breast bilaterally. No skin retraction noted. Previous mammogram revealed fibrocystic breast changes. NURSING DIAGNOSIS: Pain related to changes in breast tissue Outcome Identification and Evaluation

The client will demonstrate a decrease in breast pain as evidenced by a pain rating of 1 or 2 on a pain rating scale of 0 to 10 and statements that pain is lessened. Interventions: Relieving Pain

• Ask client to rate her pain using a numeric pain rating scale to establish a baseline. • Discuss with client any measures used to relieve pain to determine effectiveness of the measures. • Encourage use of a supportive bra to aid in reducing discomfort. • Instruct client in use of over-the-counter analgesics to promote pain relief.

• Advise the client to apply warm compresses or allow warm water from the shower to flow over her breasts to promote vasodilation and subsequent pain relief. • Tell client to reduce her intake of salt to reduce risk of fluid retention and swelling leading to increased pain.

NURSING DIAGNOSIS: Deficient knowledge related to fibrocystic breast changes and appropriate care measures Outcome Identification and Evaluation

The client will verbalize understanding of condition as evidenced by statements about the cause of breast changes and appropriate choices for lifestyle changes, and demonstration of self-care measures. Interventions: Providing Client Education

• Assess client’s knowledge of fibrocystic breast changes to establish a baseline for teaching. • Explain the role of monthly hormonal level changes and describe the signs and symptoms to promote understanding of this condition. • Teach the client how to perform breast self-examination after her menstrual period to monitor for changes. • Encourage client to report any changes promptly to ensure early detection of problems. • Suggest client speak with her primary care provider about the use of oral contraceptives to help stabilize monthly hormonal levels. • Review lifestyle choices, such as eating a low-fat diet rich in fruits, vegetables, and grains, and adhering to screening recommendations to promote health. • Discuss measures for pain relief to minimize discomfort associated with breast changes.

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Nursing Management The nurse should urge the client to return for reevaluation in 6 months, perform monthly breast self-examinations, and return annually for a clinical breast examination.

Mastitis Mastitis is an infection or inflammation of the connective tissue in the breast that occurs primarily in lactating or engorged women. Mastitis is divided into lactational or nonlactational types. The usual causative organisms for lactational mastitis are Staphylococcus aureus, Haemophilus influenzae, and Haemophilus and Streptococcus species, the source of which is the baby’s flora. One or more of the ducts drain poorly or become blocked, resulting in bacterial growth in the retained milk (Bope & Kellerman, 2012). The only evidence-based predisposing factor that may lead to mastitis is the development of milk stasis. However, other associated factors include damaged or cracked nipples, especially those colonized with Staphylococcus aureus; irregular or missed feedings; failing to allow the infant to empty one breast completely before moving on to the next breast; poor latch and transfer of milk; illness of mother or infant; oversupply; a tight bra; blocked nipple pore or duct; and maternal stress and fatigue (Summers, 2011). Nonlactational mastitis can be caused by duct e ­ ctasia, which occurs when the milk ducts become congested with secretions and debris, resulting in periductal inflammation. It may be divided into central (periareolar) and peripheral breast lesions. Periareolar infections consist of active inflammation around nondilated subareolar breast ducts—a condition termed periductal mastitis. ­Peripheral nonlactating breast abscesses are less common than periareolar abscesses and are often associated with an underlying condition such as diabetes, rheumatoid arthritis, steroid treatment, granulomatous lobular mastitis, and trauma (Liu & Peng, 2011). Women with these types of abscesses present with greenish nipple discharge, nipple retraction, and noncyclical pain.

Therapeutic Management The main purpose of the management of lactating mastitis is the frequent removal of milk to prevent milk stasis and drug therapy. Management of both types of mastitis involves the use of oral antibiotics (usually a penicillinase-resistant penicillin or cephalosporin) and acetaminophen (Tylenol) for pain and fever (Summers, 2011).

Nursing Assessment Assess the client’s health history for risk factors for mastitis, which include poor handwashing, ductal abnormalities, nipple cracks and fissures, lowered maternal

FIGURE  6.3 Mastitis. (From Sweet, R. L., & Gibbs, R. S. [2005]. Atlas of infectious diseases of the female genital tract. Philadelphia, PA: Lippincott Williams & Wilkins.)

defenses due to fatigue, tight clothing, poor support of pendulous breasts, failure to empty the breasts properly while breast-feeding, or missing breast-feedings. Assess the client for clinical manifestations of mastitis, which include flu-like symptoms of malaise, leukocytosis, fever, and chills. Physical examination of the breasts reveals increased warmth, redness, tenderness, and swelling. The nipple is usually cracked or abraded and the breast is distended with milk (Fig.  6.3). Ultrasound scans can be undertaken to differentiate between the types of mastitis or abscesses, but typically the diagnosis is made based on history and examination.

Nursing Management Teach the woman about the etiology of mastitis and encourage her to continue to breast-feed, emphasizing that it is safe for her infant to do so. Stress to all breast-feeding mothers to check for medication safety before taking it. Drugs administered to mothers can accumulate in the bodies of their infants and can alter infant’s bowel flora, causing diarrhea. Mothers should be warned about this to reduce their anxiety. Once it has been declared safe to do so, the nurse should urge them to take the medication as prescribed until completed. Continued emptying of the breast or pumping improves the outcome, decreases the duration of symptoms, and decreases the incidence of breast abscess. Thus, continued breast-feeding is recommended in the presence of mastitis (Summers, 2011). Even though 80% of breast biopsy results prove to be benign, increased surveillance is necessary because of the risk of cancer development. The recommended follow-up schedule is imaging (mammography or ultrasound) and a clinical breast exam by a surgeon at 6, 12, and 24 months after a benign breast biopsy finding (Summers, 2011). Instructions for the woman with mastitis are detailed in Teaching Guidelines 6.2.



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Teaching Guidelines 6.2 CARING FOR MASTITIS • Take medications as prescribed. • Continue breast-feeding, as tolerated. • Begins feeds on most affected breast to allow it to be emptied first • Massage the breasts before and during breast-feeding to encourage milk extraction. • Wear a supportive bra 24 hours a day to support the breasts. • Increase fluid intake. • Make sure infant is positioned correctly on the nipple. • Practice good handwashing techniques. • Apply warm compresses to the affected breast or take a warm shower before breast-feeding. • Frequently change positions while nursing. • Get adequate rest and nutrition to support or improve the immune system. Adapted from American Cancer Society [ACS]. (2011g). Non-­cancerous breast conditions. Retrieved from http://www.cancer.org/Healthy/ FindCancerEarly/WomensHealth/Non-CancerousBreastConditions/ non-cancerous-breast-conditions-fibrocystic-changes ; American Cancer Society [ACS]. (2011a). American Cancer Society guidelines for the early detection of breast cancer. Retrieved from http://www.cancer. org/Healthy/FindCancerEarly/CancerScreeningGuidelines/americancancer-society-guidelines-for-the-early-detection-of-cancer; Blackburn, S. T. (2012). Maternal, fetal & neonatal physiology (4th ed.). St. Louis, MO: Saunders Elsevier; and Summers, A. (2011). Managing mastitis in the emergency department. Emergency Nurse, 19(6), 22–25.

MALIGNANT BREAST DISORDERS Breast cancer is a neoplastic disease in which normal body cells are transformed into malignant ones (National Cancer Institute [NCI], 2011a). It is the most common cancer in women and the second leading cause of cancer deaths (lung cancer is first) among American women. Breast cancer accounts for one of every three cancers diagnosed in the United States (ACS, 2011b). A new case is discovered every 2 minutes. It is estimated that one out of every seven women will develop the disease at some time during her life, and the mortality rate of those with breast cancer is 1 in 30 (NCI, 2011a). Over 200,000 cases of invasive breast cancer are diagnosed in the United States each year (ACS, 2011b). Breast cancer can also affect men, but only 1% of all individuals diagnosed with breast cancer annually are men (Reis, Dias, Castro, & Ferreira, 2011). Because men are not routinely screened for breast cancer, the diagnosis is often delayed. The most common clinical manifestation of male breast cancer is a painless, firm, subareolar breast mass. Any suspicious breast mass in a male should undergo diagnostic biopsy. If a malignancy is diagnosed, typical treatment is mastectomy with assessment of the axillary nodes.

Breast cancer incidence rates are higher in nonHispanic White women compared to African American women for most age groups. However, African American women have a higher incidence rate before 40 years of age and are more likely to die from breast cancer at every age (ACS, 2011c). Some of that gap is due to social factors such as poverty and restricted access to health care. Some studies have also found genetic differences in the type of breast cancer that develops in Black and White women. Little is known, however, about whether other risk factors have a different impact in women of different races. A new study’s findings suggest that the risk factors are similar in both races (ACS, 2011c). The cause of breast cancer, while not well understood, is thought to be a complex interaction between environmental, genetic, and hormonal factors. Breast cancer is a progressive rather than a systemic disease, meaning that most cancers grow from small size with low metastatic potential to larger size and greater metastatic potential (Hurvitz, 2011).

I

Consider This

t was pouring down rain and I was driving alone along dark wet streets to my 8 AM appointment for a breast ultrasound. I recently had my annual mammogram and the radiologist thought he saw something suspicious on my right breast. I was on my way to confirm or refute his suspicions, and I couldn’t keep focused on the road ahead. For the past few days I had been a basket case, fearing the worst. I was playing in my mind, what I would do if . . .? What changes would I make in my life and how would I react when told? I have been through such personal turmoil since that doctor announced he wanted “more tests.” Thoughts: This woman is worrying and is emotionally devastated before she even has a conclusive diagnosis. Is this a typical reaction to a breast disorder? Why do women fear the worst? Many women use denial to mask their feelings and hope against hope the doctor made a mistake or misread their mammogram. How would you react if you or your sister, girlfriend, or mother were confronted with a breast disorder?

Pathophysiology Cancer is not just one disease, but rather a group of diseases that result from unregulated cell growth. Without regulation, cells divide and grow uncontrollably until they eventually form a tumor. Extensive research has determined that all cancer is the result of changes in DNA or chromosome structure that cause the mutation of specific genes. Most genetic mutations that cause cancer are acquired sporadically, which means they occur by chance

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and are not necessarily due to inherited mutations (Dixon, 2012). Cancer development is thought to be clonal in nature, which means that each cell is derived from another cell. If one cell develops a mutation, any daughter cell derived from that cell will have that same mutation, and this process continues until a malignant tumor forms. Breast cancer starts in the epithelial cells that line the mammary ducts within the breast. The growth rate depends on hormonal influences, mainly estrogen and progesterone. The two major categories of breast cancer are noninvasive and invasive. Noninvasive, or in situ, breast cancers are those that have not extended beyond their duct, lobule, or point of origin into the surrounding breast tissue. Conversely, invasive, or infiltrating, breast cancers have extended into the surrounding breast tissue, with the potential to metastasize. Many researchers believe that most invasive cancers probably originate as noninvasive cancers (Iwuchukwu, Wahed, Wozniak, Dordea, & Rich, 2011). By far the most common breast cancer is invasive ductal carcinoma, which represents 85% of all cases (ACS, 2011b). Carcinoma is a malignant tumor that occurs in epithelial tissue; it tends to infiltrate and give rise to metastases. The incidence of this cancer peaks in the sixth decade of life (.60  years old). It spreads rapidly to axillary and other lymph nodes, even while small. Infiltrating ductal carcinoma may take various histologic forms—well differentiated and slow growing, poorly differentiated and infiltrating, or highly malignant and undifferentiated with numerous metastases. This common type of breast cancer starts in the ducts, breaks through the duct wall, and invades the fatty breast tissue (Swart & Downey, 2011). Invasive lobular carcinomas, which originate in the terminal lobular units of breast ducts, account for 10% to 15% of all cases of breast cancer. The tumor is frequently located in the upper outer quadrant of the breast, and by the time it is discovered the prognosis is usually poor (Gomes, Balabram, Porto, & Gobbi, 2011). Other invasive types of cancer include tubular carcinoma (29%), which is fairly uncommon and typically occurs in women aged 55 and older. Colloid carcinoma (2% to 4%) occurs in women 60 to 70 years of age and is characterized by the presence of large pools of mucus interspersed with small islands of tumor cells. Medullary carcinoma accounts for 5% to 7% of malignant breast tumors; it occurs frequently in younger women (,50 years of age) and grows into large tumor masses. Inflammatory breast cancer (,4%) often presents with skin edema, redness, and warmth and is associated with a poor prognosis. Paget’s disease (2% to 4%) originates in the nipple and typically occurs with invasive ductal carcinoma (Bope & Kellerman, 2012). Breast cancer is considered to be a highly variable disease. While the process of metastasis is a complex and poorly understood phenomenon, there is evidence to suggest that new vascularization of the tumor plays an important role in the biologic

­ TABLE 6.2

STAGING OF BREAST CANCER

Stage

Characteristics

0

In situ, early type of breast cancer

I

Localized tumor ,1 inch in diameter

II

Tumor 1–2 inches in diameter; spread to axillary lymph nodes

III

Tumor 2 inches or larger; spread to other lymph nodes and tissues

IV

Cancer has metastasized to other body organs

Adapted from American Cancer Society [ACS]. (2011e). How is breast cancer staged? Retrieved from http://www.cancer.org/ Cancer/BreastCancer/DetailedGuide/breast-cancer-staging.

aggressiveness of breast cancer (Duncan & Shulman, 2011). Breast cancer metastasizes widely and to almost all organs of the body, but primarily to the bone, lungs, lymph nodes, liver, and brain. The first sites of metastases are usually local or regional, involving the chest wall or axillary supraclavicular lymph nodes or bone (ACS, 2011b). Breast cancers are classified into three stages based on: 1. Tumor size 2. Extent of lymph node involvement 3. Evidence of metastasis The purposes of tumor staging are to determine the probability that the tumor has metastasized, to decide on an appropriate course of therapy, and to assess the client’s prognosis. Table  6.2 gives details and characteristics of each stage. The overall 10-year survival rate for a woman with stage I breast cancer is 80% to 90%; for a woman with stage II, it is about 50%. The outlook is not as good for women with stage III or IV disease (Alexander et al., 2010). There is no completely accurate way to know whether the cancer has micrometastasized to distant organs, but certain tests can help determine if the cancer has spread. A bone scan can be performed to assess the bones. Magnetic resonance imaging (MRI) can be used to detect metastases to the liver, abdominal cavity, lungs, or brain.

Risk Factors An estimated 80% of women in whom breast cancer develops have no documented risk factors (Bope & Kellerman, 2012). Breast cancer is thought to develop in response to a number of related factors: aging; gender (99% of cases occur in women), delayed childbearing or never bearing children, genetic influences); BRCA1 and BRCA2 genetic mutations; history of receiving ionizing radiation; high breast density; postmenopausal obesity; family history of cancer; hormonal factors such as



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early menarche ,12  years, late menopause .50  years, first term pregnancy .30 to 35  years of age; hormone replacement therapy with estrogen plus progestin; and ingestion of two drinks or more alcohol each day (ACS, 2011b). Other factors might contribute to breast cancer but have not been scientifically proven. In 1970, the lifetime risk for developing breast cancer was 1 in 10; since then, the risk has gradually risen (NCI, 2011a). This slight increase in incidence might be explained in a variety of ways: better detection and screening tools are available, which have identified more cases; women are living to an older age, when their risk increases; and lifestyle changes in American women (having their first pregnancy at an older age, having fewer children, and using hormonal therapy to treat the symptoms of menopause) might have produced the higher numbers. Age is a significant risk factor. Because rates of breast cancer increase with age, estimates of risk at specific ages are more meaningful than estimates of lifetime risk. The estimated chances of a woman being diagnosed with breast cancer between the ages of 30 and 70 are detailed in Table 6.3. Risk factors for breast cancer can be divided into those that cannot be changed (nonmodifiable risk factors) and those that can be changed (modifiable risk factors). Nonmodifiable risk factors (ACS, 2011h) are: • Gender (female) • Aging (.50 years old) • Genetic mutations (BRCA1 and BRCA2 genes) • Personal history of ovarian or colon cancer • Increased breast density • Family history of breast cancer • Personal history of breast cancer (three- to fourfold increase in risk for recurrence) • Race (higher in Caucasian women, but African American women are more likely to die of it) • Previous abnormal breast biopsy (atypical hyperplasia) • Exposure to chest radiation (radiation damages DNA) • Previous breast radiation (12 times normal risk) • Early menarche (,12 years old) or late onset of menopause (.55 years old), which represents increased estrogen exposure over the lifetime

­ TABLE 6.3

ESTIMATED RISK OF BREAST CANCER AT SPECIFIC AGES

Ages 30–39

1 out of 233

Ages 40–49

1 out of 69

Ages 50–59

1 out of 42

Ages 60–69

1 out of 29

Adapted from National Cancer Institute [NCI]. (2011b). Probability of breast cancer in American women. Retrieved from http://www.cancer.gov/cancertopics/factsheet/detection/ probability-breast-cancer.

Modifiable risk factors related to lifestyle choices (ACS, 2011h) include: • Not having children at all or not having children until after age 30—this increases the risk of breast cancer by not reducing the number of menstrual cycles • Postmenopausal use of estrogens and progestins— the Women’s Health Initiative study (2002) reported increased risks with long-term (.5 years) use of hormone replacement therapy • Failing to breast-feed for up to a year after ­pregnancy— increases the risk of breast cancer because it does not reduce the total number of lifetime menstrual cycles • Alcohol consumption—boosts the level of estrogen in the bloodstream • Smoking—exposure to carcinogenic agents found in cigarettes • Obesity and consumption of high-fat diet—fat cells produce and store estrogen, so more fat cells create higher estrogen levels • Sedentary lifestyle and lack of physical exercise—­ increases body fat, which houses estrogen The presence of risk factors, especially several of them, calls for careful ongoing monitoring and evaluation to promote early detection. Even though risk factors are important considerations, many women with newly diagnosed breast cancer have no known risk factors. Although routine mammography and self-examination are prudent for high-risk women, these precautions may become lifesavers for early detection of cancerous lesions. Consuming a low-fat diet with plenty of fruits, vegetables, legumes, and whole grains can provide all the vitamins and nutrients our bodies need and has been shown to significantly reduce the risk of developing many types of cancer. A plant-based diet can also reduce cancer recurrence: high-fiber, low-fat diets rich in fruits and vegetables reduce breast cancer recurrence, according to a new report from the Women’s Healthy Eating and Living (WHEL) Study (Flatt, 2011). The WHEL study was a multisite, randomized controlled trial of the effectiveness of a high-vegetable, low-fat diet, aimed at markedly raising circulating carotenoid concentrations from food sources, in reducing additional breast cancer events and early death in women with early-stage invasive breast cancer. It is a prescription for cancer prevention that has only positive side effects—lower cholesterol, weight loss, and a lower risk of heart disease.

Diagnosis Many studies can be performed to make an accurate diagnosis of a malignant breast lump. Diagnostic tests include: • Diagnostic mammography or digital mammography • Magnetic resonance mammography (MRM)

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• Fine-needle aspiration • Stereotactic needle-guided biopsy • Sentinel lymph node biopsy • Hormone receptor status • DNA ploidy status • Cell proliferative indices • HER-2/neu genetic marker (Luedders et al., 2011)

Mammography Mammography involves taking x-ray pictures of a bare breast while it is compressed between two plastic plates. This procedure is a screening tool used to identify and characterize a breast mass and to detect an early malignancy. It remains the “gold standard” screening method for women at average risk for breast cancer (Kreimer, 2011). It is relatively inexpensive, requires only a low dose of radiation, and reliably identifies malignant tumors, especially those that are too small to feel. It can also be used to investigate breast lumps and other symptoms. A screening mammogram typically consists of four views, two per breast (Fig.  6.4). It can detect lesions as small as 0.5 cm (the average

size of a tumor detected by a woman practicing occasional breast self-examination is approximately 2.5 cm) (Gøtzsche & Nielsen, 2011). A diagnostic mammogram is performed when a woman has suspicious clinical findings on a breast examination or an abnormality has been found on a screening mammogram. A diagnostic mammogram uses additional views of the affected breast as well as magnification views. Diagnostic mammography provides the radiologist with additional detail to render a more specific diagnosis. In 2000, the U.S. Food and Drug Administration approved the use of digital mammography, which has many of the same advantages as digital photography. Digital mammography, which records images in computer code instead of on x-ray film, can also be used so that images can be transmitted and easily stored. Digital images can be enlarged, and the contrast can be adjusted, allowing radiologists to concentrate on suspicious areas and especially to improve the detection of tumors in dense breast tissue. The images can also be stored and transmitted electronically, for ready comparison from year to year and for consultations with experts at a distance. According to the Digital Mammography Imaging Screening Trial (involving almost 50,000 women), the difference between film and digital mammography is negligible for most women over age 50, but digital images have an edge over film for three other, often overlapping groups: women under age 50, women who are pre- or perimenopausal, and women who have dense breasts (Advances in Breast Imaging, 2010). Most women find the 10-minute mammography procedure uncomfortable but not painful. Teaching Guidelines 6.3 offers tips for a client to follow before she undergoes this procedure. The U.S. Preventive Services Task Force (USPSTF) changed its recommendations for breast cancer screening

A

Teaching Guidelines 6.3 PREPARING FOR A SCREENING MAMMOGRAM

B FIGURE 6.4 Mammography. (A) A top-to-bottom view of the breast. (B) A side view of the breast.

• Schedule the procedure just after menses, when breasts are less tender. • Do not use deodorant or powder the day of the procedure, because they can appear on the x-ray film as calcium spots. • Acetaminophen (Tylenol) or aspirin can relieve any discomfort after the procedure. • Remove all jewelry from around your neck, because the metal can cause distortions on the film image. • Select a facility that is accredited by the American College of Radiology to ensure appropriate credentialed staff.



in 2009, resulting in considerable controversy. The USPSTF now recommends biennial screening mammography for women aged 50 to 74 years. Previously, women 40 years and older were advised to start screening mammography. They stated that the decision to start regular, biennial screening mammography before the age of 50 years should be an individual one and take client context into account, including the client’s values regarding specific benefits and harms. In addition, the USPSTF concluded that the current evidence is insufficient to assess the additional benefits and harms of screening mammography in women 75 years or older. Finally, the USPSTF recommended against teaching breast self-examination (BSE) because scientific evidence does not support this practice as a valid screening method for women since its sensitivity ranges from 12% to 41%, lower than that of the clinical breast exam done by a health professional and mammography, and it is age dependent (USPSTF, 2009). The American Cancer Society has different guidelines for women with no symptoms or family history of breast cancer than the USPSTF. They still recommend annual mammograms and clinical breast exams for women starting at age 40 and do not recommend stopping them at any age. They suggest that BSEs can be optional for women from age 20 onward (ACS, 2011a). The American Congress of Obstetricians and Gynecologists (ACOG) recommends mammography screening be offered annually to women beginning at age 40. Previous ACOG guidelines recommended mammograms every 1 to 2 years starting at age 40 and annually beginning at age 50. ACOG continues to recommend annual clinical breast exams (CBEs) for women aged 40 and older, and every 1 to 3  years for women aged 20 to 39. Additionally, it encourages “breast self-awareness” for women ages 20 and older (ACOG, 2011). This conflicting information can be confusing to women trying to make decisions about breast cancer screening. Nurses can present the latest evidence-based research to help women make informed decisions based on their age, overall health status, and family history of cancer. (See Table 6.4 for a helpful outline.) There really isn’t any clear “direction” given to women by the authoritative agencies; they in essence leave the decision up to the woman and her health care provider. The associated risk is delay in detecting a breast lesion early when it could be treated and her life saved.

Magnetic Resonance Mammography MRM is a relatively new procedure that might allow for earlier detection because it can detect smaller lesions and provide finer detail. MRM is a highly accurate (.90% sensitivity for invasive carcinoma) but costly tool. Contrast infusion is used to evaluate the rate at which the dye initially enters the breast tissue. The basis of the high sensitivity of MRM is the tumor angiogenesis (vessel growth)

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that accompanies a majority of breast cancers, even early ones. Malignant lesions tend to exhibit increased enhancement within the first 2 minutes (Levrini et al., 2011). Currently MRM is used as a complement to mammography and CBE because it is expensive, but recent research findings report that it is more accurate than mammography for size assessment of breast lesions (Levrini et al., 2011).

Fine-Needle Aspiration Biopsy Fine-needle aspiration biopsy is done to identify a solid tumor, cyst, or malignancy. It is a simple office procedure that can be performed with or without anesthesia. A small (20- to 22-gauge) needle connected to a 10-mL or larger syringe is inserted into the breast mass and suction is applied to withdraw the contents. The aspirate is then sent to the cytology laboratory to be evaluated for abnormal cells.

Stereotactic Needle-Guided Biopsy This diagnostic tool is used to target and identify mammographically detected nonpalpable lesions in the breast. This procedure is less expensive than an excisional biopsy. The procedure takes place in a specially equipped room and generally takes about an hour. When proper placement of the breast mass is confirmed by digital mammograms, the breast is locally anesthetized and a spring-loaded biopsy gun is used to obtain two or three core biopsy tissue samples. After the procedure is finished, the biopsy area is cleaned and a sterile dressing is applied.

Sentinel Lymph Node Biopsy The status of the axillary lymph nodes is an important prognostic indicator in early-stage breast cancer. The presence or absence of malignant cells in lymph nodes is highly significant: the more lymph nodes involved and the more aggressive the cancer, the more powerful chemotherapy will have to be, both in terms of the toxicity of drugs and the duration of treatment (Wiatrek & ­Kruper, 2011). With a sentinel lymph node biopsy, the clinician can determine whether breast cancer has spread to the axillary lymph nodes without having to do a traditional axillary lymph node dissection. Experience has shown that the lymph ducts of the breast typically drain to one lymph node first before draining through the rest of the lymph nodes under the arm. The first lymph node is called the sentinel lymph node. This procedure can be performed under local anesthesia. A radioactive blue dye is injected 2 hours before the biopsy to identify the afferent sentinel lymph node. The surgeon usually removes one to three nodes and sends them to the pathologist to determine whether cancer cells

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TABLE 6.4

SCREENING RECOMMENDATIONS FROM USPSTF, ACS, AND ACOG

The U.S. Preventive Services Task Force

In 2009, the USPSTF changed its recommendations for breast cancer screening for women with no symptoms or no family history of breast cancer. Previous they advised screening mammography for women ages 40 years and older. Updated recommendations include biennial screening mammography for women ages 50 to 74 years, and no breast self-examination (BSE) since scientific evidence does not support this practice as a valid screening method for women because its sensitivity ranges from 12% to 41%, which is lower than that of the clinical breast exam done by a health professional and mammography, and it is age dependent. The USPSTF states that a woman’s decision to start regular, biennial screening mammography before the age of 50 years should be an individual one and take client context into account, including the client’s values regarding specific benefits and harms. The USPSTF also reports that current evidence is insufficient to assess the additional benefits and harmful aspects of screening mammography in women 75 years or older (USPSTF, 2009).

The American Cancer Society

Guidelines from the ACS differ from those of the USPSTF for women with no symptoms or no family history of breast cancer. The ACS still recommends annual mammograms and clinical breast exams for women starting at age 40 and do not recommend stopping them at any age. They suggest that BSEs can be optional for women from age 20 onward (ACS, 2011a).

The American Congress of O ­ bstetricians and Gynecologists

The ACOG recommends screening mammograms be offered annually to women beginning at age 40. Previous guidelines recommended a mammogram every 1 to 2 years starting at age 40 and annually beginning at age 50. Clinical breast exams are still recommended every year, but BSEs are optional and not strongly recommended (ACOG, 2011).

are present. The sentinel lymph node biopsy is usually performed before a lumpectomy to make sure the cancer has not spread. Removing only the sentinel lymph node can allow women with breast cancer to avoid many of the side effects (lymphedema) associated with a traditional axillary lymph node dissection (­Velloso, Barra, & Dias, 2011).

Hormone Receptor Status Normal breast epithelium has hormone receptors and responds specifically to the stimulatory effects of estrogen and progesterone. Most breast cancers retain estrogen receptors, and for those tumors estrogen will retain proliferative control over the malignant cells. It is therefore useful to know the hormone receptor status of the cancer to predict which women will respond to hormone manipulation. Hormone receptor status reveals whether the tumor is stimulated to grow by estrogen and progesterone. Postmenopausal women tend to be ER1; premenopausal women tend to be ER– (Harmer, 2011). To

determine hormone receptor status, a sample of breast cancer tissue obtained during a biopsy or a tumor removed surgically during a lumpectomy or mastectomy is examined by a cytologist.

Therapeutic Management Women diagnosed with breast cancer have many treatments available to them. Generally, treatments fall into two categories: local and systemic. Local treatments are surgery and radiation therapy. Effective systemic treatments include chemotherapy, hormonal therapy, and immunotherapy. (See the Evidence-Based Practice feature in this chapter for additional information.) Treatment plans are based on multiple factors, with the primary factors being whether the cancer is invasive or noninvasive, the tumor’s size and grade, the number of cancerous axillary lymph nodes, the hormone receptor status, and the ability to obtain clear surgical margins (ACS, 2011a). A combination of surgical options and adjunctive therapy is often recommended.



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EVIDENCE-BASED PRACTICE 6.1

CHEMOTHERAPY ALONE VERSUS ENDOCRINE THERAPY ALONE FOR METASTATIC BREAST CANCER

Breast cancer is the most commonly diagnosed cancer in women. If the cancer has spread beyond the breast (metastatic disease), treatments include chemotherapy (anticancer drugs) and endocrine therapy (also known as hormonal treatment). Endocrine therapy is mainly given to women whose cancer is determined to be hormone responsive, that is, where hormone receptors (estrogen or progesterone receptors) are expressed in the tumor cells.

STUDY The objective of this study was to see if starting treatment with chemotherapy or starting treatment with endocrine therapy provides more benefit in terms of survival, response to treatment, toxicity from treatment, and quality of life. Ten eligible studies were identified, eight of which provided information on response to treatment (in 817 patients) and six on overall survival (in 692 patients). Trials were generally old (published between 1963 and 1995) and small in size (median of 70 women, range 50 to 226 women in each trial) and were of modest quality. The types of chemotherapy used were reasonably conventional by today’s standards; the endocrine therapies varied considerably.

Findings This study found that while initial treatment with chemotherapy rather than endocrine therapy may be associated with a higher response rate, the two initial treatments had a similar effect on overall survival. No single group of women who might benefit from or be

harmed by one treatment over the other were identified, although there was little information to address this question. Six of the seven fully published trials commented on increased toxicity associated with chemotherapy including nausea, vomiting, and alopecia. Three of the seven trials mentioned aspects of quality of life but their findings provided differing results. Only one trial formally measured quality of life (QOL), concluding that QOL was better with chemotherapy. Based on these trials, no conclusions can be made as to the QOL achieved with either treatment.

Nursing Implications Although not entirely conclusive in their findings, nurses need to be aware of this study’s findings to be able to counsel women when both therapies are being considered. This study suggests that accurate information about both therapies is needed for all women with metastatic breast cancer, for them to make an informed decision. The effectiveness of hormonal treatments has improved during the past 10 years and thus should be considered an option. In women with metastatic breast cancer where hormone receptors are present, a policy of treating first with endocrine therapy rather than chemotherapy appears to be better on the basis of the trials and outcomes in this review, except in the presence of rapidly progressive disease. Nurses need to remember that once breast cancer is metastatic it is no longer curable, but it is treatable. The aim of selecting either treatment is to improve the woman’s quality and length of life.

Adapted from Wilcken, N., Hornbuckle, J., & Ghersi, D. (2011). Chemotherapy alone versus endocrine therapy alone for metastatic breast cancer. Cochrane Database of Systematic Reviews, 2011(7). doi:10.1002/14651858.CD002747.

Another consideration in making decisions about a treatment plan is genetic testing for BRCA1 and BRCA2 genetic mutations. This genetic testing became available in 1995 and can pinpoint women who have a significantly increased risk for breast and ovarian cancer: individuals with BRCA1 and BRCA2 mutations have a 75% lifetime risk of breast cancer and a 30% lifetime risk of ovarian cancer. Most cases of breast and ovarian cancer are sporadic in nature, but approximately 10% of breast and ovarian cancers are thought to result from genetic inheritance (Eccles, 2011). Testing positive for a BRCA1 or BRCA2 mutation can significantly alter health care decisions. In some cases, before genetic testing was available, lumpectomy with radiation or mastectomy was the treatment most often recommended. However, if the woman is found to have a BRCA1 mutation, she is most likely to be offered the option of bilateral prophylactic mastectomy and possible bilateral oophorectomy (Mislowsky et al., 2011).

Discovery of mutations in the breast and ovarian cancer susceptibility genes BRCA1 and BRCA2 can have emotional consequences for both the tested individual and his or her relatives. Severe psychological distress can occur as a result of genetic testing. Their distress relates to family cancer history, relationships, coping strategies, communication patterns, and mutation status (Harmer, 2011). Nurses might find it useful to explore these issues in order to prepare clients before BRCA1/BRCA2 testing and to support them through shifts in family dynamics after disclosure of results. Also, many women perceive their breasts as intrinsic to their femininity, self-esteem, and sexuality, and the risk of losing a breast can provoke extreme anxiety (Alexander et al., 2010). Nurses need to address the physical, emotional, and spiritual needs of the women they care for, as well as their families, since this mutation is inherited in an autosomal dominant fashion. Based on Mendelian genetics, women with BRCA1 and BRCA2 mutations have a 5- to 20-fold increased risk of developing breast and ovarian cancer (Kurian et al., 2011).

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Surgical Options Generally, the first treatment option for a woman diagnosed with breast cancer is surgery. A few women with tumors larger than 5 cm or inflammatory breast cancer may undergo neoadjuvant chemotherapy or radiotherapy to shrink the tumor before surgical removal is attempted (Waljee, Ubel, Atisha, Hu, & Alderman, 2011). The surgical options depend on the type and extent of cancer. The choices are typically either breast-conserving surgery (lumpectomy with radiation) or mastectomy with or without reconstruction. The overall survival rate with lumpectomy and radiation is about the same as that with modified radical mastectomy (ACS, 2011a). Research has shown that the survival rates in women who have had mastectomies versus those who have undergone breastconserving surgery followed by radiation are the same. However, lumpectomy may not be an option for some women, including those: • Who have two or more cancer sites that cannot be removed through one incision • Whose surgery will not result in a clean margin of tissue • Who have active connective tissue conditions (lupus or scleroderma) that make body tissues especially ­sensitive to the side effects of radiation • Who have had previous radiation to the affected breast • Whose tumors are larger than 5 cm (2 inches) ­(National Comprehensive Cancer Network [NCCN], 2011). These decisions are made jointly between the woman and her surgeon. If mastectomy is chosen, because of either tumor characteristics or client preference, then discussion needs to include breast reconstruction and regional lymph node biopsy versus sentinel lymph node biopsy. The mastectomy techniques are a simple mastectomy with sentinel node biopsy or a radical mastectomy with regional node biopsy. Removal of numerous lymph nodes places the client at high risk for lymphedema. BREAST-CONSERVING SURGERY Breast-conserving surgery, the least invasive procedure, is the wide local excision (or lumpectomy) of the tumor along with a 1-cm margin of normal tissue. A lumpectomy is often used for early-stage localized tumors. The goal of breast-conserving surgery is to remove the suspicious mass along with tissue free of malignant cells to prevent recurrence. The results are less drastic and emotionally less scarring than having a mastectomy to the woman. Women undergoing breast-conserving therapy receive radiation after lumpectomy with the goal of eradicating residual microscopic cancer cells to limit locoregional recurrence. In women who do not require adjuvant chemotherapy, radiation therapy typically begins 2 to 4 weeks after surgery to allow healing of the lumpectomy incision site. Radiation is administered to the

entire breast at daily doses over a period of several weeks (Recht & Solin, 2011). A sentinel lymph node biopsy may also be performed since the lymph nodes draining the breast are located primarily in the axilla. Theoretically, if breast cancer is to metastasize to other parts of the body, it will probably do so via the lymphatic system. If malignant cells are found in the nodes, more aggressive systemic treatment may be needed. MASTECTOMY A simple mastectomy is the removal of all breast tissue, the nipple, and the areola. The axillary nodes and pectoral muscles are spared. This procedure would be used for a large tumor or multiple tumors that have not metastasized to adjacent structures or the lymph system. A modified radical mastectomy is another surgical option; conducive to breast reconstruction and results in greater mobility and less lymphedema (Alexander et al., 2010). This procedure involves removal of breast tissue, and a few positive axillary nodes. Breast-conserving surgeries do not increase the future risk of death from recurrent disease when compared mastectomy (Schuiling & Likis 2013). In conjunction with the mastectomy, lymph node surgery (removal of underarm nodes) may need to be done to reduce the risk of distant metastasis and improve a woman’s chance of long-term survival. For women with a positive sentinel node biopsy, 10 to 20 underarm lymph nodes may need to be removed. Complications associated with axillary lymph node surgery include nerve damage during surgery, causing temporary numbness down the upper aspect of the arm; seroma formation followed by wound infection; restrictions in arm mobility (some women need physiotherapy); and lymphedema. In many women lymphedema can be avoided by: • Avoiding using the affected arm for drawing blood, inserting intravenous lines, or measuring blood pressure (can cause trauma and possible infection) • Seeking medical care immediately if the affected arm swells • Wearing gloves when engaging in activities such as gardening that might cause injury • Wearing a well-fitted compression sleeve to promote drainage return Women having mastectomies must decide whether to have further surgery to reconstruct the breast. If the woman decides to have reconstructive surgery, it ideally is performed immediately after the mastectomy. The woman must also determine whether she wants the surgeon to use saline implants or natural tissue from her abdomen (TRAM flap method) or back (LAT flap method). If reconstructive surgery is desired, the ultimate decision regarding the method will be determined by the



woman’s anatomy (e.g., is there sufficient fat and muscle to permit natural reconstruction?) and her overall health status. Both procedures require a prolonged recovery period. Some women opt for no reconstruction, and many of them choose to wear breast prostheses. Some prostheses are worn in the bra cup and others fit against the skin or into special pockets created into clothing. Whether to have reconstructive surgery is an individual and very complex decision. Each woman must be presented with all of the options and then allowed to decide. The nurse can play an important role here by presenting the facts to the woman so that she can make an intelligent decision to meet her unique situation.

Adjunctive Therapy Adjunctive therapy is supportive or additional therapy that is recommended after surgery. Adjunctive therapies include local therapy such as radiation therapy and systemic therapies using chemotherapy, hormonal therapy, and immunotherapy. RADIATION THERAPY Radiation therapy uses high-energy rays to destroy cancer cells that might have been left behind in the breast, chest wall, or underarm area after a tumor has been removed surgically. Usually serial radiation doses are given 5 days a week to the tumor site for 6 to 8 weeks postoperatively. Each treatment takes only a few minutes, but the dose is cumulative. Women undergoing breastconserving therapy receive radiation to the entire breast after lumpectomy with the goal of eradicating residual microscopic cancer cells to reduce the chance of recurrence (McCloskey, Lee, & Steinberg, 2011). Side effects of traditional radiation therapy include inflammation, local edema, anorexia, swelling, and heaviness in the breast; sunburn-like skin changes in the treated area; and fatigue. Changes to the breast tissue and skin usually resolve in about a year in most women (van Oorschot, Beckmann, Schulze, Rades, & Feyer, 2011). This type of therapy can be given several ways: external beam radiation, which delivers a carefully focused dose of radiation from a machine outside the body, or internal radiation, in which tiny pellets that contain radioactive material are placed into the tumor. Several advances have taken place in the field of radiation oncology for the treatment of women with early-stage breast cancer that assist in reducing the side effects. The treatment position for external radiation has changed from supine to prone, with the arm on the affected side raised above the head, so that the treated breast hangs dependently through the opening of the treatment board. Treatment in the prone position improves dose distribution within the breast and allows for a decrease in the dose delivered to the heart, lung, chest wall, and other breast (NCCN, 2011).

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High-dose brachytherapy is another advance that is an alternative to traditional radiation treatment. A balloon catheter is used to insert radioactive seeds into the breast after the tumor has been removed surgically. The seeds deliver a concentrated dose directly to the operative site; this is important because most cancer recurrences in the breast occur at or near the lumpectomy site (HannounLevi, Castelli, Plesu et al., 2011). This allows a high dose of radiation to be delivered to a small target volume with a minimal dose to the surrounding normal tissue. This procedure takes 4 to 5 days as opposed to the 4 to 6 weeks that traditional radiation therapy takes; it also eliminates the need to delay radiation therapy to allow for wound healing. Brachytherapy is now used as a primary radiation treatment after breast-conserving surgery in selected women as an alternative to whole breast irradiation (HaieMeder, Siebert, & Pötter, 2011). Side effects of brachytherapy include redness or discharge around catheters, fever, and infection. Daily cleansing of the catheter insertion site with a mild soap and application of an antibiotic ointment will minimize the risk of infection. Intensity-modulated radiation therapy (IMRT) offers still another new approach to the delivery of treatment to reduce the dose within the target area while sparing surrounding normal structures. A computed tomography scan is used to create a three-dimensional model of the breast. Based on this model, a series of intensity-modulated beams is produced to the desired dose distribution to reduce radiation exposure to underlying structures. Acute toxicity is thus minimized (Harmer, 2011). Research is ongoing to evaluate the impact of all of these advances in radiation therapy. CHEMOTHERAPY Chemotherapy refers to the use of drugs that are toxic to all cells and interfere with a cell’s ability to reproduce. They are particularly effective against malignant cells but affect all rapidly dividing cells, especially those of the skin, the hair follicles, the mouth, the gastrointestinal tract, and the bone marrow. Breast cancer is a systemic disease in which micrometastases are already present in other organs by the time the breast cancer is diagnosed. Chemotherapeutic agents perform a systemic “sweep” of the body to reduce the chances that distant tumors will start growing. Chemotherapy may be indicated for women with tumors larger than 1 cm, positive lymph nodes, or cancer of an aggressive type. Chemotherapy is prescribed in cycles, with each period of treatment followed by a rest period. Treatment typically lasts 3 to 6  months, depending on the dose used and the woman’s health status. Different classes of drugs affect different aspects of cell division and are used in combinations or “cocktails.” The most active and commonly used chemotherapeutic agents for breast cancer include alkylating agents,

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anthracyclines, antimetabolites, and vinca alkaloids. Fifty or more chemotherapeutic agents can be used to treat breast cancer; however, a combination drug approach appears to be more effective than a single drug treatment (ACS, 2011d). Refer Table 6.1 EBP here. Side effects of chemotherapy depend on the agents used, the intensity of dosage, the dosage schedule, the type and extent of cancer, and the client’s physical and emotional status (Harmer, 2011). However, typical side effects include nausea and vomiting, diarrhea or constipation, hair loss, weight loss, stomatitis, fatigue, and immunosuppression. The most serious is bone marrow suppression (myelosuppression). This causes an increased risk of infection, bleeding, and a reduced red blood cell count, which can lead to anemia. Treatment of the side effects can generally be addressed through appropriate support medications such as antinausea drugs. In addition, growth-stimulating factors, such as epoetin alfa (Procrit) and filgrastim (Neupogen), help keep blood counts from dropping too low. Counts that are too low would stop or delay the use of chemotherapy. An aggressive systemic option, when other treatments have failed or when there is a strong possibility of relapse or metastatic disease, is high-dose chemotherapy with bone marrow and/or stem cell transplant. This therapy involves the withdrawal of bone marrow before the administration of toxic levels of chemotherapeutic agents. The marrow is frozen and then returned to the client after the high-dose chemotherapy is finished. Clinical trials are still researching this experimental therapy (Harmer, 2011). HORMONAL THERAPY One of estrogen’s normal functions is to stimulate the growth and division of healthy cells in the breasts. However, in some women with breast cancer, this normal function contributes to the growth and division of cancer cells. The objective of endocrine therapy is to block or counter the effect of estrogen. Estrogen plays a central role in the pathogenesis of cancer, and treatment with estrogen deprivation has proven to be effective (Amir, Seruga, Niraula, Carlsson, & Ocaña 2011). Several different drug classes are used to interfere or block estrogen receptors. They include selective estrogen receptor modulators (SERMs), estrogen receptor down-regulators, aromatase inhibitors, luteinizing hormone-releasing hormone, progestin, and biologic response modifiers (King & Brucker, 2011). Current recommendations for most women with ER1 breast cancer are to take a hormonelike ­ medication—known as a SERM antiestrogenic agent—daily for up to 5 years after initial treatment. Certain areas in the female body (breasts, uterus, ovaries, skin, vagina, and brain) contain specialized cells called hormone receptors that allow estrogen to enter the cell and stimulate it to divide. SERMs enter these same receptors and act like keys, turning off the signal for growth

inside the cell (King & Brucker, 2011). The best-known SERM is tamoxifen (Nolvadex, 20 mg daily for 5 years). Although it works well in preventing further spread of cancer, it is also associated with an increased incidence of endometrial cancer, pulmonary embolus, deep vein thrombosis, hot flashes, vaginal discharge and bleeding, stroke, and cataract formation (Rivera-Guevara & C ­ amacho, 2011). Another SERM is the anti-osteoporosis drug raloxifene (Evista), which has shown promising results. It has antiestrogen effects on the breast and uterus. In recent studies involving postmenopausal women at high risk for breast cancer, raloxifene worked as well as tamoxifen in preventing breast cancer, but with fewer serious adverse effects. Both drugs cut the cancer risk in half (Rivera-Guevara & Camacho, 2011). It was originally marketed solely for the prevention and treatment of osteoporosis but is now used as adjunctive breast cancer therapy. Another class of endocrine agents, aromatase inhibitors, works by inhibiting the conversion of androgens to estrogens. Aromatase inhibitors include letrozole ­(Femara, 2.5 mg daily), exemestane (Aromasin, 25 mg daily), and anastrozole (Arimidex, 1 mg daily for 5 years), all of which are taken orally. These are usually given to women with advanced breast cancer. In recent clinical studies in postmenopausal women with breast cancer, third-generation aromatase inhibitors were shown to be superior to tamoxifen for the treatment of metastatic disease (Lonning, 2011). The side effects associated with these endocrine therapies include hot flashes, bone pain, fatigue, nausea, cough, dyspnea, and headache (Hackley et al., 2010). Women with hormone-sensitive cancers can live for long periods without any intervention other than hormonal manipulation, but quality-of-life issues need to be addressed in the balance between treatment and side effects. IMMUNOTHERAPY Immunotherapy, used as an adjunct to surgery, represents an attempt to stimulate the body’s natural defenses to recognize and attack cancer cells. Trastuzumab ­(Herceptin, 2- to 4-mg/kg intravenous infusion) is the first monoclonal antibody approved for breast cancer (NCCN, 2011). Some tumors produce excessive amounts of HER-2/neu protein, which regulates cancer cell growth. Breast cancers that overexpress the HER-2/neu protein are associated with a more aggressive form of disease and a poorer prognosis. Trastuzumab blocks the effect of this protein to inhibit the growth of cancer cells. It can be used alone or in combination with other chemotherapy to treat clients with metastatic breast disease (Slamon et al., 2011). Adverse effects of trastuzumab include cardiac toxicity, vascular thrombosis, hepatic failure, fever, chills, nausea, vomiting, and pain with first infusion (Skidmore-Roth, 2011).



NURSING PROCESS FOR THE CLIENT WITH BREAST CANCER When a woman is diagnosed with breast cancer, she faces treatment that may alter her body shape, may make her feel unwell, and may not carry a certainty of cure. Nurses can support women from the time of diagnosis, through the treatments, and through follow-up after the surgical and adjunctive treatments have been completed. Allowing clients time to ask questions and to discuss any necessary preparations for treatment is critical. As our understanding of breast disorders keeps improving, treatments continue to change. Although the goal of treatment remains improved survival, increasing emphasis is being focused on prevention. Breast cancer prevention measures focus on evaluating and reducing risk factors (Strayer & Schub, 2011). Nurses can have an impact on early detection of breast disorders, treatment, and symptom management. Women with a cancer diagnosis often experience negative emotions and nurses’ empathic response can help alleviate their distress (Alexander et al., 2011). A nurse who is involved in the woman’s treatment plan from the beginning can effectively offer support throughout the whole experience. Teamwork is important in breast screening and caring for women with breast disorders. Treatment is often fragmented between the hospital and community treatment centers, which can be emotionally traumatic for the woman and her family. The advances being made in the diagnosis and treatment of breast disorders mean that guidelines are constantly changing, requiring all health care professionals to keep up to date. Informed nurses can provide support and information and, most importantly, continuity of care for the woman undergoing treatment for a breast problem. The nurse plays a particularly important role in providing psychological support and self-care teaching to clients with breast cancer. Nurses can influence both physical and emotional recovery, which are both important aspects of care that help in improving the woman’s quality of life and the ability to survive. The nurse’s role should extend beyond helping clients; spreading the word in the community about screening and prevention is a big part in the ongoing fight against cancer. The community should see nurses as both educators and valued sources of credible information. This role will help improve clinical outcomes while achieving high levels of client satisfaction. Despite the new guidelines issued by various governmental agencies regarding self-breast exams, a clinical breast exam done by a professional health care provider is essential for good breast health for all women. See Box  6.1 for additional information.

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Remember Nancy from the chapter opener? Is her response typical of many women upon discovering a lump in their breast? Nancy confides her discovery of the lump and her worries to you. What advice would you give her?

ASSESSMENT Early breast cancer has no symptoms. The earliest sign of breast cancer is often an abnormality seen on a screening mammogram before the woman or the health care professional feels it. A healthy, asymptomatic presentation is typical. However, symptoms may include a lump in the breast that is usually nontender, fixed, and hard with irregular borders. In the woman presenting with a breast disorder, take a thorough history of the problem and explore the woman’s risk factors for breast cancer. Assess the woman for clinical manifestations of breast cancer, such as changes in breast appearance and contour, which become apparent with advancing breast cancer (ACS, 2011a). These changes include: • Continued and persistent changes in the breast • A lump or thickening in one breast • Persistent nipple irritation • Unusual breast swelling or asymmetry • A lump or swelling in the axilla • Changes in skin color or texture • Nipple retraction, tenderness, or discharge (Fig. 6.5) Complete a breast examination to validate the clinical manifestations and findings of the health history and risk factor assessment. The clinical breast examination involves both inspection and palpation (Box 6.1). Helpful characteristics in evaluating palpable breast masses are described in Table 6.5. If a lump can be palpated, the cancer has been there for quite some time. Be cognizant of the impact that breast cancer has on a woman’s emotional state, coping ability, and quality of life. Women may experience sadness, anger, fear, and guilt as a result of having breast cancer. However, despite potential negative outcomes, many women have a positive outlook for their future and adapt to treatment modalities with a good quality of life (Harmer, 2011). Closely monitor clients for their psychosocial adjustment to diagnosis and treatment and be able to identify those who need further psychological intervention. By giving practical advice, the nurse can help the woman adjust to her altered body image and to accept the changes in her life. Because family members play a significant role in supporting women through breast cancer diagnosis and treatment, assess the emotional distress of both partners during the course of treatment and, if needed, make a referral for psychological counseling. By identifying

216   U N I T 2   Women’s Health Throughout the Life Span BOX 6.1

CLINICAL BREAST EXAMINATION BY HEALTH CARE PROVIDER If the woman is deemed high risk, the nurse would then teach the woman to perform a breast self-examination to enhance breast awareness. Purpose: To Assess Breasts for Abnormal Findings 1. Inspect the breast for size, symmetry, and skin texture and color. It is common for the left breast to be slightly larger than the right. Inspect the nipples and areola. Ask the client to sit at the edge of the examination table, with her arms resting at her sides.

•T  he client then stands, places her hands on her hips, and leans forward.

3. P  alpate the breasts using the pads of your first three fingers and make a rotary motion on the breast. Assist the client into a supine position with her arms above her head. Place a pillow or towel under the client’s head to help spread the breasts. Three patterns might be used to palpate the breasts:

2. Inspect the breast for masses, retraction, dimpling, or ecchymosis. • The client places her hands on her hips.

• Spiral

• S he then raises her arms over her head so the ­axillae can also be inspected.



C h a p t e r 0 6   Disorders of the Breasts    217 BOX 6.2 CLINICAL BREAST EXAMINATION BY HEALTH CARE PROVIDER

• Pie-shaped wedges

(continued)

4. Compress the nipple gently between the thumb and index finger to evaluate for masses and squeeze to check for any discharge.

• Vertical strip 5. P  alpate the axillary area for any tenderness or lymph node enlargement. Have the client sit up and move to the edge of the examination table. While supporting the client’s arm, palpate downward from the armpit, palpating toward the ribs just below the breast.

Adapted from Jarvis, C. (2012). Physical examination & health assessment (6th ed.). St. Louis, MO: Elsevier Saunders.

FIGURE 6.5 Stages I to IV of breast cancer.

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TABLE 6.5

CHARACTERISTICS OF BENIGN VS. MALIGNANT BREAST MASSES

Benign Breast Masses are Described as

Malignant Breast Masses are Described as

• Frequently painful

• Hard to palpation

• Firm, rubbery mass

• Painless

• Bilateral masses

• Irregularly shaped (poorly delineated)

• Induced nipple discharge

• Immobile, fixed to the chest wall

• Regular margins (clearly delineated)

• Skin dimpling

• No skin dimpling

• Nipple retraction

• No nipple retraction

• Unilateral mass

• Mobile, not affixed to the chest wall

• Bloody, serosanguineous, or serous nipple discharge

• No bloody discharge

• Spontaneous nipple discharge

interpersonal strains, negative psychosocial side effects of cancer treatment can be minimized.

NURSING DIAGNOSIS Appropriate nursing diagnoses for a woman with a diagnosis of breast cancer might include: • Disturbed body image related to: • Loss of body part (breast) • Loss of femininity • Loss of hair due to chemotherapy • Fear related to: • Diagnosis of cancer • Prognosis of disease • Educational deficit related to: • Cancer treatment options • Reconstructive surgery decisions • Breast self-examination

NURSING INTERVENTIONS Offer information, support, and perioperative care to women diagnosed with breast cancer who are undergoing treatment. Implement health promotion and disease prevention strategies to minimize the risk for developing breast cancer and to promote optimal outcomes.

Remember Nancy, who discovered a breast lump? You offer to go with her to the doctor. After a full examination and several diagnostic tests, the results come back positive for breast cancer. What treatment options does Nancy have, and what factors need to be considered in selecting those options?

Providing Client Education Help the woman and her partner to prioritize the ­voluminous amount of information given to them so that they can make informed decisions. Explain all treatment options in detail so the client and her family understand them. By preparing an individualized packet of information and reviewing it with the woman and her partner, the nurse can help them understand her specific type of cancer, the diagnostic studies and treatment options she may choose, and the goals of treatment. For example, nurses play an important role in educating women about the use of endocrine therapies, observing women’s experiences with treatment, and communicating those observations to their primary care professionals to make dosage adjustments, in a­ ddition to contributing to the knowledge base of endocrine therapy in the treatment of breast cancer. Providing information is a central role of the nurse in caring for the woman with a diagnosis of breast cancer. This information can be given via telephone counseling, one-to-one contact, and pamphlets. Telephone counseling with women and their partners may be an effective method to improve symptom management and quality of life. Educate women on living with risk, maintaining quality of life, and participating in support groups (Strayer & Schub, 2011).

Providing Emotional Support The diagnosis of cancer affects all aspects of life for a woman and her family. The threatening nature of the disease and feelings of uncertainty about the future can lead to anxiety and stress. Address the woman’s need for: • Information about diagnosis and treatment • Physical care while undergoing treatments • Contact with supportive people



• Education about disease, options, and prevention measures • Discussion and support by a caring, competent nurse Reassure the client and her family that the diagnosis of breast cancer does not necessarily mean imminent death, a decrease in attractiveness, or diminished sexuality. Encourage the woman to express her fears and worries. Be available to listen and address the woman’s concerns in an open manner to help her toward recovery. All aspects of care must include sensitivity to the client’s personal efforts to cope and heal. Some women will become involved in organizations or charities that support cancer research; they may participate in breast cancer walks to raise awareness or become a Reach for Recovery volunteer to help others. Each woman copes in her own personal manner, and all of these efforts can be positive motivators for her own healing. To help women cope with the diagnosis of breast cancer, the ACS launched Reach to Recovery more than 30 years ago. Specially trained breast cancer survivors give women and their families’ opportunities to express their feelings, verbalize their fears, and get answers. Most importantly, Reach to Recovery volunteers offer understanding, support, and hope through face-to-face visits or by telephone; they are proof that people can survive breast cancer and live productive lives. National contact information is 1-800-ACS-2345.

Providing Postoperative Care For the woman who has had surgery to remove a malignant breast lump or an entire breast, excellent postoperative nursing care is crucial. Tell the woman what to expect in terms of symptoms and when they usually occur during treatment and after surgery. This allows women to anticipate these symptoms and proactively employ management strategies to improve their cancer experience. Postoperative care includes immediate postoperative care, pain management, care of the affected arm, wound care, mobility care, respiratory care, emotional care, referrals, and educational needs.

Immediate Postoperative Care Assess the client’s respiratory status by auscultating the lungs and observing the breathing pattern. Assess circulation; note vital signs, skin color, and skin temperature. Observe the client’s neurologic status by evaluating the level of alertness and orientation. Monitor the wound for amount and color of drainage. Monitor the intravenous lines for patency, correct fluid, and rate. Assess the drainage tube for amount, color, and consistency of drainage.

Pain Management Provide analgesics as needed. Reassure the woman that her pain will be controlled. Teach the woman how to

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communicate her pain intensity on a scale of 0 to 10, with 10 being the worst pain imaginable. Assess the client’s pain level frequently and anticipate pain before assisting the woman to ambulate.

Affected Arm Care Elevate the affected arm on a pillow to promote lymph drainage. Make sure that no treatments are performed on the affected arm, including laboratory draws, intravenous lines, blood pressures, and so on. Place a sign above the bed to warn others not to touch the affected arm.

Wound Care Observe the wound often and empty drainage reservoirs as needed. Tell the client to report any evidence of infection early, such as fever, chills, or any area of redness or inflammation along the incision line. Also tell the client to report any increase in drainage, foul odor, or separation at the incision site.

Mobility Care Perform active range-of-motion and arm exercises as ordered. Encourage self-care activities for successful rehabilitation. Perform dressing and drainage care; explain the care during the procedure.

Respiratory Care Assist with turning, coughing, and deep breathing every 2 hours. Explain that this helps to expand collapsed alveoli in the lungs, promotes faster clearance of inhalation agents from the body, and prevents postoperative pneumonia and atelectasis.

Emotional Care and Referrals Encourage the client to participate in her care. Assess her coping strategies preoperatively. Explain possible body image concerns after discharge. Promote the ACS web sites, which provide the latest cancer therapy news. Encourage the client to attend local support groups for breast cancer survivors, such as Reach to Recovery, an ACS program in which trained volunteers provide support and up-to-date information for spouses, children, friends, and other loved ones. Reach to Recovery volunteers can also, when appropriate, provide a temporary breast form and give information on types of permanent prostheses, as well as lists of where those items are available in the community.

Educational Needs Provide follow-up information about adjunctive therapy. Explain that radiation therapy may start within weeks postoperatively. Discuss chemotherapy, its side

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effects and cycles, home care during treatment, and future monitoring strategies. Explain hormonal therapy, including antiestrogens or aromatase inhibitors. Teach progressive arm exercises to minimize lymphedema. Explain that ongoing surveillance is needed to detect recurrence of cancer or a new primary site and that the client will typically see the health care provider every 6 months.

Nancy underwent a mastectomy with ­radiation and chemotherapy. What ­follow-up care is needed? How can the nurse assist Nancy to cope with her uncertain future? What community resources might help her?

IMPLEMENTING HEALTH PROMOTION AND DISEASE PREVENTION STRATEGIES In the past, most women assumed that there was little they could do to reduce their risk of developing breast cancer. However, research has found that the v choices women make concerning breast cancer screening, diet, exercise, and other health practices have a profound impact on cancer risk. In the fight against cancer, nurses often assume a variety of roles, such as educator, counselor, advocate, and role model. Nurses can offer education about the following: • Prevention • Early detection • Screening • Dispelling myths and fears • Self-examination techniques if needed • Individual risk status and strategies for risk reduction It is important to be knowledgeable about the most current evidence-based practices and cognizant of how the media presents this information. Offer prevention strategies within the context of a woman’s life. Factors such as lifestyle choices, economic status, and multiple roles need to be taken into consideration when counseling women. Advocate for healthy lifestyles and making sound choices to prevent cancer. Nurses, like all health care professionals, should offer guidance from a comprehensive perspective that acknowledges the unique needs of each individual. Nurses need to not only be proficient in the postoperative physical care of clients who undergo mastectomy but also demonstrate advanced skills related to the educational needs of clients and their families and to ensure care is delivered in a manner that is client centered and individualized. Nurses require advanced skills to meet the social and psychological care needs

of the woman and her family during this major life event (Hughes, Edward, & Hyett, 2011). Breast cancer is a frightening experience for all women but is particularly burdensome on African American women, ranking second among the cause of cancer deaths in them. Although the incidence of breast cancer is highest in Caucasian women, African American women have a higher breast cancer mortality rate at every age and a lower survival rate than any other racial or ethnic group. Statistics indicate that the gap is widening (ACS, 2011c). Like a black cloud hanging over their heads, with little regard for any victim, breast cancer stalks women everywhere they go. Many have a close friend or relative who is battling the disease; many have watched their mothers and sisters die of this dreaded disease. Those with risk factors live with even greater anxiety and fear. No woman wants to hear those chilling words: “The biopsy is positive. You have breast cancer.” Provide women with information about detection and risk factors, inform them about the new ACS screening guidelines, instruct them on breast self-examination, and outline dietary changes that might reduce their risk of breast cancer. Awareness is the first step toward a change in habits. Raising the level of awareness about breast cancer is of paramount importance, and nurses can play an important role in health promotion, disease prevention, and education.

Breast Cancer Screening The three components of early detection are breast self-­ examination, clinical breast examination, and mammography. The ACS (2011a) has issued breast cancer screening guidelines that, for the first time, offer specific guidance for the women and greater clarification of the role of breast examinations (Table  6.4). ACS screening guidelines are revised about every 5 years to include new scientific findings and developments. Women are exposed to multiple sources of cancer prevention information, and much of it may not be sound. Discuss the benefits, risks, and potential limitations of breast self-examination, clinical breast examination, and mammography with each woman and tailor the information to her specific risk factors (ACS, 2011h). Based on the new guidelines, make clinical judgments as to the appropriateness of recommending breast self-examination, and reevaluate the need to teach the procedure to all women; the focus might instead be on encouraging regular mammograms (depending, of course, on the woman’s individual risk factors). Breast self-examination is a technique that enables a woman to detect any changes in her breasts. BSEs, once thought essential for early breast cancer detection,



are now considered optional. Instead, breast awareness is stressed. Breast awareness refers to a woman being familiar with the normal consistency of both breasts and the underlying tissue. This emphasis is now on awareness of breast changes, not just discovery of cancer. Research has shown that breast self-examination plays a small role in detecting breast cancer compared with self-awareness. However, doing breast self-examination is one way for a woman to know how her breasts normally feel so that she can notice any changes that do occur (ACS, 2011a). If appropriate, there are two steps to conducting a BSE: visual inspection and tactile palpation. The visual part should be done in three separate positions: with the arms up behind the head, with the arms down at the sides, and bending forward. Instruct the woman to look for: • Changes in shape, size, contour, or symmetry • Skin discoloration or dimpling, bumps/lumps • Sores or scaly skin • Discharge or puckering of the nipple In the second part, the tactile examination, the health care provider feels the woman’s breasts in one of three specific patterns: spiral, pie-shaped wedges, or a vertical strip (up and down). When using any of the three patterns, the woman should use a circular rubbing motion (in dime-sized circles) without lifting the fingers. The examiner checks not only the breasts but also between the breast and the axilla, the axilla itself, and the area above the breast up to the clavicle and across the shoulder. The pads of the three middle fingers on the right hand are used to assess the left breast; the pads of the three middle fingers on the left hand are used to assess the right breast. Instruct the woman to use three different degrees of pressure: • Light (move the skin without moving the tissue underneath) • Medium (midway into the tissue) • Hard (down to the ribs)

Nutrition Nutrition plays a critical role in health promotion and disease prevention. Cancer is considered to be a chronic disease that may be influenced at many stages by nutrition. These factors may affect prevention, progression, and treatment of the disease (Lutz & Przytulski, 2011). Being overweight or obese is a risk factor for breast cancer in postmenopausal women. Excess body weight has been linked to an increased risk of postmenopausal breast cancer, and growing evidence also suggests that obesity is associated with poor prognosis in women diagnosed with early-stage breast cancer. Dozens of studies demonstrate that women who are overweight or obese at the time of breast cancer diagnosis are at

C h a p t e r 0 6   Disorders of the Breasts    221

increased risk of cancer recurrence and death compared with leaner women, and some evidence suggests that women who gain weight after breast cancer diagnosis may also be at increased risk of poor outcomes (Ligibel, 2011). Healthy People 2020 identified being overweight or obese as one of the 10 leading health indicators and a major health concern (U.S. Department of Health and Human Services, 2010). Almost 65% of women over the age of 20 years are overweight; of these, 33.4% are obese (Ligibel, 2011). A diet high in fruits, vegetables, and high-fiber carbohydrates and low in animal fats seems to offer protection against breast cancer as well as weight control. Women who followed these dietary guidelines decreased their risk of breast cancer (Lutz & Przytulski, 2011). The Women’s Health Initiative Dietary Modification Trial (Carty et al., 2011) was designed to study a lowfat diet, a nutritional approach to prevention of chronic diseases. It found a marginally statistically significant reduction in breast cancer incidence among women in the low-fat dietary pattern group. The American Institute for Cancer Research, which conducts extensive research, made the following recommendations to reduce a woman’s risk for developing breast cancer: • Engaging in daily moderate exercise and weekly vigor­ ous physical activity • Consuming at least five servings of fruits and vegetables daily • Not smoking or using any tobacco products • Keeping a maximum body mass index (BMI) of 25 and limiting weight gain to no more than 11 pounds since age 18 • Consuming seven or more daily portions of complex carbohydrates, such as whole grains and cereals • Limiting intake of processed foods and refined sugar • Restricting red meat intake to approximately 3 ounces daily • Limiting intake of fatty foods, particularly those of animal origin • Restricting intake of salted foods and use of salt in cooking (Pekmezi & Demark-Wahnefried, 2011) The medical community is also starting to study the role of phytochemicals in health. The unique geographic variability of breast cancer around the world and the low rate of breast cancer in Asian compared to Western countries prompted this interest. This area of research appears hopeful for women seeking to prevent breast cancer as well as those recovering from it. Although the mechanism is not clear, certain foods demonstrate anticancer properties and boost the immune system. Phytochemicalrich foods include: • Green tea and herbal teas • Garlic

222   U N I T 2   Women’s Health Throughout the Life Span

• Whole grains and legumes • Onions and leeks • Soybeans and soy products • Tomato products (cooked tomatoes) • Fruits (citrus, apricots, pumpkin, berries) • Green leafy vegetables (spinach, collards, romaine) • Colorful vegetables (carrots, squash, tomatoes) • Cruciferous vegetables (broccoli, cabbage, cauliflower) • Flax seeds (Lutz & Przytulski, 2011). Adopt a holistic approach when addressing the nutritional needs of women with breast cancer. Incorporate nutritional assessment into the general overall assessment of all women. Culturally sensitive nutritional assessment tools need to be developed and used to enhance this process. Providing examples of appropriate foods associated with the woman’s current dietary habits, relating current health status to nutritional intake, and placing proposed modifications within a realistic personal framework may increase a woman’s willingness to incorporate needed changes in her nutritional behavior. Be able to interpret research results and stay up to date on nutritional influences so that you can transmit this key information to the public.

KEY CONCEPTS Many women believe that all lumps are cancerous, but actually more than 80% of the lumps discovered are benign and need no treatment (Alexander et al., 2010). The most commonly encountered benign breast disorders in women include fibrocystic breasts, fibroadenomas, and mastitis (Bope & Kellerman, 2012). Current research suggests that women with fibrocystic breast disease or other benign breast conditions are more likely to develop breast cancer later only if a breast biopsy shows “atypia” or abnormal breast cells (ACS, 2011g).

References Advances in breast imaging. (2010). Harvard Women’s Health Watch, 17(9), 1–3. Alexander, L. L., LaRosa, J. H., Bader, H., & Garfield, S. (2010). New dimensions in women’s health (5th ed.). Sudbury, MA: Jones & Bartlett. Alexander, S. C., Pollak, K. I., Morgan, P. A., Strand, J., Abernethy, A. P., Jeffreys, A. S., ... Tulsky, J. A. (2011). How do non-physician clinicians respond to advanced cancer patients’ negative expressions of emotions?. Supportive Care in Cancer, 19(1), 155–159. Aliotta, H. M., & Schaeffer, N. J. (2010). Breast conditions. In K. D. Schuiling & F. E. Likis (Eds.), Women’s gynecologic health (pp. 331–348). Sudbury, MA: Jones & Bartlett. American Cancer Society [ACS]. (2011a). American Cancer Society guidelines for the early detection of breast cancer. Retrieved from http://www.cancer.org/Healthy/FindCancerEarly/

Fibroadenomas are common benign solid breast tumors that can be stimulated by external estrogen, progesterone, lactation, and pregnancy. Mastitis is an infection of the connective tissue in the breast that occurs primarily in lactating or engorged women; it is divided into lactational or nonlactational types. Management of both types of mastitis involves the use of oral antibiotics (usually a penicillinase-­ resistant penicillin or cephalosporin) and acetaminophen (Tylenol) for pain and fever (Summers, 2011). Breast cancer is the most common cancer in women and the second leading cause of cancer deaths (lung cancer is first) among American women (ACS, 2011b). Breast cancer metastasizes widely and to almost all organs of the body, but primarily to the bone, lungs, lymph nodes, liver, and brain. The etiology of breast cancer is unknown, but the disease is thought to develop in response to a number of related factors: aging, delayed childbearing or never bearing children, high breast density, family history of cancer, late menopause, obesity, and hormonal factors. Breast cancer treatments fall into two categories: local and systemic. Local treatments are surgery and radiation therapy. Effective systemic treatments include chemotherapy, hormonal therapy, and immunotherapy. Women commonly perceive their breasts as intrinsic to their femininity, self-esteem, and sexuality, and the risk of losing a breast can provoke extreme anxiety. Nurses can influence both physical and emotional recovery, which are both important aspects of care that help in improving the woman’s quality of life and the ability to survive. Providing up-to-date information and emotional support are central roles of the nurse in caring for the woman with a diagnosis of breast cancer.

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CHAPTER W O R K S H E E T MULTIPLE-CHOICE QUESTIONS

CRITICAL THINKING EXERCISES

1. Breast self-examinations involve both touching of breast tissue and: a. Palpation of cervical lymph nodes b. Firm squeezing of both breast nipples c. Visualizing both breasts for any change d. A mammogram to evaluate breast tissue

1. Mrs. Gordon, 48, presents to the women’s community clinic where you work as a nurse. She is very upset and crying. She tells you that she found lumps in her breast: “I know that it’s cancer and I will die.” When you ask her about her problem, she says she does not check her breasts monthly and hasn’t had a mammogram for years because “they’re too expensive.” She also describes the intermittent pain she experiences. a. What specific questions would you ask this client to get a clearer picture? b. What education is needed for this client regarding breast health? c. What community referrals are needed to meet this client’s future needs?

2. Which of the following is the strongest risk factor for breast cancer? a. Advancing age and being female b. High number of children c. Genetic mutations in BRCA1 and BRCA2 genes d. Family history of colon cancer 3. A biopsy procedure that traces radioisotopes and blue dye from the tumor site through the lymphatic system into the axillary nodes is: a. Stereotactic biopsy b. Sentinel node biopsy c. Axillary dissection biopsy d. Advanced breast biopsy 4. The most serious potential adverse reaction from chemotherapy is: a. Thrombocytopenia b. Deep vein thrombosis c. Alopecia d. Myelosuppression 5. What suggestion would be helpful for the client experiencing painful fibrocystic breast changes? a. Increase her caffeine intake. b. Take a mild analgesic when needed. c. Reduce her intake of leafy vegetables. d. Wear a bra bigger than she needs. 6. A postoperative mastectomy client should be referred to which of the following organizations for assistance? a. National Organization for Women (NOW) b. Food and Drug Administration (FDA) c. March of Dimes Foundation (MDF) d. Reach to Recovery (RTR)

2. Ruth Davis, 51, stops in at the urgent care facility with an anxious look on her face. She tells the nurse practitioner that she has green discharge coming from her right breast and discomfort intermittently. She can’t understand how this would happen since she hasn’t previously had any nipple discharge or pain. a. What benign breast condition might the nurse practitioner suspect based on her description? b. What specific information should the nurse practitioner give Mrs. Davis about duct ectasia? c. The typical treatment of this benign breast condition would include what? STUDY ACTIVITIES 1. Discuss with a group of women what their breasts symbolize to them and to society. Do they symbolize something different to each one? 2. When a woman experiences a breast disorder, what feelings might she be experiencing and how can a nurse help her sort them out? 3. Interview a woman who has fibrocystic breast changes and find out how she manages this condition. 4. An infection of the breast connective tissue that frequently occurs in the lactating woman is ___________________.

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7 KEY TERMS cystocele enterocele Kegel exercises ovarian cyst pelvic organ prolapse (POP) pessary polycystic ovary syndrome (PCOS) polyps rectocele urinary incontinence (UI) uterine fibroids uterine prolapse

Benign Disorders of the Female Reproductive Tract Learning Objectives Upon completion of the chapter, you will be able to: 1. Define the key terms used in this chapter. 2. Identify the major pelvic relaxation disorders in terms of etiology, management, and nursing interventions. 3. Outline the nursing management needed for the most common benign reproductive disorders in women. 4. Evaluate urinary incontinence in terms of pathology, clinical manifestations, treatment options, and effect on quality of life. 5. Compare the various benign growths in terms of their symptoms and management. 6. Analyze the emotional impact of polycystic ovarian syndrome and the nurse’s role as a counselor, educator, and advocate.

Liz, a 26-year-old, overweight woman, presented to the clinic with hirsutism and facial acne and told the nurse she was concerned about her irregular menstrual periods. She also said that recently the hair on top of her head seemed to be falling out. What diagnostic tests might the nurse anticipate with this client? How can the nurse prepare Liz for them?

WOW

Words of Wisdom

Women can influence their aging process by making wise lifestyle choices early on.



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The incidence of several benign pelvic disorders i­ncreases as women age. For instance, women may experience pelvic support disorders related to pelvic relaxation or urinary incontinence. These disorders generally develop after years of wear and tear on the muscles and tissues that support the pelvic floor—such as that which occurs with childbearing, chronic coughing, straining, surgery, or simply aging. In addition to pelvic support disorders, woman may also experience various benign neoplasms of the reproductive tract, such as cervical polyps, uterine leiomyomas (fibroids), ovarian cysts, genital fistulas, and Bartholin’s cysts. This chapter provides an overview of various pelvic support disorders and benign neoplasms, discussing the assessment, treatment, and prevention strategies for each. It also addresses female genital cutting in the context of it being a harmful practice that affects girls’ and women’s health.

PELVIC SUPPORT DISORDERS Pelvic support disorders such as pelvic organ prolapse or genital prolapse and urinary and fecal incontinence are common in aging women. Researchers funded by the National Institutes of Health (NIH) (2011) reported that nearly 24% of U.S. women are affected with one or more pelvic floor disorders. The study reported that the frequency of pelvic floor disorders increases with age, affecting more than 40% of women from 60 to 79 years of age, and about 50% of women 80 years and older. The NIH analysis is the first to document in a nationally representative sample the extent of pelvic floor disorders, a cluster of health problems that causes physical discomfort and limits activity. Pelvic support disorders cause significant physical and psychological morbidity and can diminish women’s social interactions, emotional well-being, and overall quality of life. Because pelvic support disorders increase with age, the problem will grow worse as our population ages. These disorders occur as a result of weakness of the connective tissue and muscular support of pelvic organs due to a number of factors: vaginal childbirth, obesity, lifting, chronic cough, straining at defecation secondary to constipation, and estrogen deficiency (American College of Obstetricians and Gynecologists [ACOG], 2010b). The female anatomy is susceptible to the development of pelvic floor disorders because of its vertical structures placement. The bony pelvis has an exaggerated lumbar spinal curve and downward tilt to it. The bladder rests on the symphysis and the posterior organs rest on the sacrum and coccyx. The pelvis holds the organs, but a woman’s erect posture causes a funneling effect and constant downward pressure.

Pelvic Organ Prolapse Pelvic organ prolapse (POP) (from the Latin prolapsus, “a slipping forth”) refers to the abnormal descent or

herniation of the pelvic organs from their original attachment sites or their normal position in the pelvis. POP occurs when structures of the pelvis shift and protrude into or outside of the vaginal canal. The Egyptians were the first to describe prolapse of the genital organs. Hippocrates in 400 BC made reference to placing a pomegranate half into the vagina to treat organ prolapse. A disorder exclusive to women, POP rarely results in severe morbidity or mortality but can affect a woman’s daily activities and quality of life (Lazarou & Grigorescu, 2011). It is difficult to determine the incidence of POP, because the disorder is often asymptomatic and many women do not seek treatment. It has been estimated, however, that up to 75% of all women who have had a vaginal birth experience POP (ACOG, 2010b). Each year, over 250,000 women undergo surgery to repair the prolapse at a cost of over $1 billion for hospitalization and physician fees alone (Hullfish, Trowbridge, & Stukenborg, 2011). With the aging of the population, POP and its associated symptoms are becoming increasingly common (Tinelli et al., 2010). Obesity can also aggravate symptoms of pelvic organ prolapse and stress urinary incontinence and increase the risk of endometrial polyps and symptomatic fibroids. Weight reduction enhances reproductive outcomes, diminishes symptoms of urinary incontinence, and reduces morbidity following gynecologic surgery. Sustained and substantial weight loss, however, is difficult to achieve for many women with their current lifestyle and dietary choices (Pandey & Bhattacharya, 2010). The treatment and diagnosis of POP is challenging and problematic.

Types of Pelvic Organ Prolapse The four most common types of pelvic or genital prolapse are cystocele, rectocele, enterocele, and uterine prolapse (Fig. 7.1): • Cystocele occurs when the posterior bladder wall protrudes downward through the anterior vaginal wall. • Rectocele occurs when the rectum sags and pushes against or into the posterior vaginal wall. • Enterocele occurs when the small intestine bulges through the posterior vaginal wall (especially common when straining). • Uterine prolapse occurs when the uterus descends through the pelvic floor and into the vaginal canal. Multiparous women are at particular risk for uterine prolapse. The extent of uterine prolapse is classified in terms of stages: • Stage 0: No descent of pelvic structure during straining. • Stage I: The prolapsed descending organ is .1 cm above the hymenal ring.

228   U N I T 2   Women’s Health Throughout the Life Span Small intestine

Bladder

Uterus Pubic bone

Cervix

Urethra

Rectum

Rectum

Vagina

Rectocele

A

B

Normal

Rectum

Rectocele and Cystocele

Small intestine

Small intestine

Bladder

Vagina

Rectum

Vagina

Rectocele

Cervix

Enterocele

C

Cystocele

Enterocele

D

Uterine Prolapse

FIGURE 7.1 Types of pelvic prolapses. (A) Normal. (B) Rectocele and cystocele. (C) Enterocele. (D) Uterine prolapse.

• Stage II: The prolapsed organ extends ~1 cm below the hymenal ring. • Stage III: The prolapsed organ extends 2–3 cm below the hymenal ring. • Stage IV: The vagina is completely everted or the prolapsed organ is .3 cm below the hymenal ring ­(Manonai et al., 2011).

Etiology Anatomic support of the pelvic organs is mainly provided by the levator ani muscle complex and the connective tissue attachments of the pelvic organ fascia. Dysfunction of one or both of these components can lead to loss of support and eventually POP. Weakened pelvic floor muscles also prevent complete closure of the urethra, resulting in urine leakage during physical stress. This problem is not limited to older women: urinary incontinence has been documented in women of varying ages, including young (,25 years old) women (Brubaker et al., 2010).

Many risk factors for POP have been suggested, but the true cause is likely to be multifactorial. Causes might include: • Constant downward gravity because of erect human posture • Atrophy of supporting tissues with aging and decline of estrogen levels • Weakening of pelvic support related to childbirth trauma • Reproductive surgery • Family history of POP • Young age at first birth • Connective tissue disorders • Infant birth weight of more than 4,500 g • Pelvic radiation • Increased abdominal pressure secondary to: • Lifting of children or heavy objects • Straining due to chronic constipation • Respiratory problems or chronic coughing • Obesity (Tinelli et al., 2010)



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Therapeutic Management

Kegel Exercises

Treatment options for POP depend on the symptoms and their effect on the woman’s quality of life. Important considerations when deciding on nonsurgical or surgical options include the severity of symptoms, the woman’s preferences, the woman’s health status, age, and suitability for surgery, and the presence of other pelvic conditions (urinary or fecal incontinence). When surgery is being considered, the nature of the procedure and the likely outcome must be fully explained and discussed with the woman and her partner. Treatment options for POP include Kegel exercises, estrogen replacement therapy, dietary and lifestyle modifications, use of pessaries or the Colpexin Sphere, and surgery (see Evidence-Based Practice 7.1).

Kegel exercises strengthen the pelvic floor muscles to support the inner organs and prevent further prolapse. Pelvic floor muscle exercises are generally accepted as first-line treatment for stress and urge urinary incontinence and they are also widely used for anal incontinence. Reasonable evidence indicates that pelvic floor muscle exercises work for urinary incontinence because the uterus itself does not play any role in the pathogenesis of uterine prolapse (Hefni & El-Toucky, 2011). The purpose of pelvic floor exercises is to increase the muscle volume, which will result in a stronger muscular contraction. Kegel exercises might limit the progression of mild prolapse and alleviate mild prolapse symptoms,

EVIDENCE-BASED PRACTICE 7.1

PELVIC FLOOR MUSCLE TRAINING VERSUS NO TREATMENT OR INACTIVE CONTROL TREATMENTS FOR URINARY INCONTINENCE IN WOMEN

STUDY Pelvic floor muscle training is the most commonly used physical therapy treatment for women with stress urinary incontinence. It is sometimes recommended for mixed incontinence and less commonly urge urinary incontinence. A wide range of treatments has been used in the management of urinary incontinence, including conservative interventions (e.g., physical therapies including pelvic floor muscle training, cones, lifestyle interventions), behavioral training (e.g., bladder training), anti-incontinence devices, pharmaceutical interventions (e.g., anticholinergics), and surgery (e.g., minimally invasive sling operations or absorbent products). This study was done to determine the effects of pelvic floor muscle training for women with urinary incontinence in comparison to no treatment, placebo or sham treatments, or other inactive control treatments.

Findings Randomized or quasi-randomized trials in women with stress, urge, or mixed urinary incontinence (based on symptoms, signs, or urodynamics) were selected for this arm of the study. One arm of the trial included pelvic floor muscle training (PFMT). Another arm was no treatment, placebo, sham, or other inactive control treatment. Fourteen trials involving 836 women (435 PFMT, 401 controls) met the inclusion criteria; but only data from 12 trials which included 672 women were studied 12 trials (672) contributed data to the analysis. Many studies were at moderate to high risk of bias, based on the trial reports. There was considerable variation in interventions used, study populations, and outcome measures. Women who did PFMT were more likely to report they were cured or improved than women who did not. Women who did PFMT also reported better continence-specific quality of life than women who did not. PFMT women also experienced fewer incontinence episodes per day and less leakage on a short office-based pad test. Of the few adverse effects reported, none were serious. The trials in stress urinary incontinent women that suggested greater benefit recommended a longer training period than the one trial in women with detrusor overactivity (urge) incontinence. Overall, the results found in this study indicated that PFMT is better than no treatment, placebo drug, or inactive control treatments for women with stress, urge, or mixed incontinence. Women with PFMT were more likely to report cure or improvement, report better quality of life, have fewer leakage episodes per day, and have less urine leakage on short pad tests than controls. The study suggested that the treatment effect (especially self-reported cure/improvement) might be greater in women with stress urinary incontinence participating in a supervised PFMT program for at least 3 months. It seems older age may not decrease the effect of PFMT in stress urinary incontinent women: in trials with stress urinary incontinent older women, both primary and secondary outcome measures appeared to be comparable to outcomes in trials in younger women.

Nursing Implications Overall, there is support for the widespread recommendation that PFMT be included in a first-line conservative management program for women with stress, urge, or mixed urinary incontinence. Nurses should continue to instruct women with incontinence to perform pelvic floor muscle training daily to improve their urinary incontinence and their quality of life. Adapted from Dumoulin, C., & Hay-Smith, J. (2010). Pelvic floor muscle training versus no treatment, or inactive control treatments, for urinary incontinence in women. Cochrane Database of Systematic Reviews, 2010(1). doi:10.1002/14651858.CD005654.pub2.

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including low back pain and pelvic pressure. They will not, however, help severe uterine prolapse.

Hormone Replacement Therapy Hormone replacement therapy (orally, transdermally, or vaginally) may improve the tone and vascularity of the supporting tissue in perimenopausal and menopausal women by increasing blood perfusion and the elasticity of the vaginal wall.

Take Note! Before hormone therapy is considered, a thorough medical history must be taken to assess a woman’s risk for complications (e.g., endometrial cancer, myocardial infarction, stroke, breast cancer, pulmonary emboli, and deep vein thrombosis). Because of these risks, estrogens, with or without progestins, should be given at the lowest effective dose and for the shortest duration consistent with the treatment goals and risks for the individual woman (ACOG, 2010a).

A

Dietary and Lifestyle Modifications Dietary and lifestyle modifications may help prevent pelvic relaxation and chronic problems later in life. Dietary habits can exacerbate the prolapse by causing constipation and consequently chronic straining. The stools of a constipated woman are hard and dry, and typically she must strain while bearing down to defecate. This straining to pass a hard stool increases intraabdominal pressure, which over time causes the pelvic organs to prolapse. Dietary modifications can help to establish regular bowel movements without discomfort and eliminate flatus and bloating. A weight loss regimen might also need to be instituted if the woman is overweight.

B FIGURE  7.2 Examples of pessaries. (A) Various shapes and sizes of pessaries available. (B) Insertion of one type of pessary. A link to a web site for a picture of Colpexin Sphere is located on .

Pessaries Vaginal pessaries are synthetic devices inserted in the vagina to provide support to the bladder and other pelvic organs as a corrective measure for urinary incontinence and/or pelvic organ prolapse (Fig.  7.2). In the past, multiple materials including fruit, metal, porcelain, rubber, and acrylic have been used to manufacture pessaries. Fortunately, today almost all pessaries are made of medical-grade silicone, which provides many advantages. Silicone pessaries are pliable and have a long shelf life; lack odor and secretion absorption; are biologically inert, nonallergenic, and noncarcinogenic; and they can be boiled or autoclaved for sterilization. Because most pessaries are made of silicone, pessary style and size are the main considerations when selecting a pessary (Manchana, 2011). Although many types and shapes are available, the most commonly used pessary is a firm ring that presses against the wall of the vagina and urethra to

help decrease leakage and support a prolapsed vagina or uterus. Pessaries are of two main types: • Support pessaries, which rest under the symphysis and sacrum and elevate the vagina (e.g., ring, Gehrung, and Hodge pessaries) • Space-occupying pessaries, which are designed to manage severe prolapse by supporting the uterus even with a lack of vaginal tone (e.g., cube, doughnut, and inflatable Gellhorn pessaries) Indications for pessary use include uterine prolapse or cystocele, especially among elderly clients for whom surgery is contraindicated; younger women with prolapse who plan to have additional children; and women with marked prolapse who prefer to use a pessary rather than undergo surgery (Lamers, Broekman, & Milani, 2011). Many women use pessaries for only a short period of time and become free of symptoms. Long-term



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use can lead to pressure necrosis in some women; in this situation other methods of support should be explored. Nurses need to be aware of the personal isolation and embarrassment and social and cultural implications that urinary incontinence may cause as well as the subjective experiences of using a pessary. With appropriate support, vaginal pessaries can provide women with the freedom to lead active, engaged social lives. Pessaries are fitted by trial and error; the woman often needs to try several sizes or styles. The largest pessary that the woman can wear comfortably is generally the most effective. The woman should be instructed to report any discomfort or difficulty with urination or defecation while wearing the pessary.

Colpexin Sphere An intravaginal device, the Colpexin Sphere supports the pelvic floor muscles and facilitates rehabilitation of those muscles. Although pessaries may support a prolapsed pelvic organ, they do not allow for concomitant strengthening of pelvic floor musculature and they do not reduce urine leakage (Harnsomboon et al., 2011). The Colpexin Sphere is a polycarbonate sphere with a locator string that is fitted above the hymenal ring to support the pelvic floor muscles. The sphere is used in conjunction with pelvic floor muscle exercises, which should be performed daily.

Surgical Interventions Surgical interventions for pelvic or genital organ prolapse are designed to correct specific defects, with the goals being to restore normal anatomy and to preserve function (Gomelsky, Penson, & Dmochowski, 2011). Surgery is not an option for all women. Women who are at high risk of suffering recurrent prolapse after a surgical repair or who have morbid obesity, chronic obstructive pulmonary disease, or medical conditions in which general anesthesia would be risky are not good candidates for surgical repair (Borstad, Abdelnoor, Staff, & KulsengHanssen, 2010), and noninvasive treatment strategies should be discussed with them. Surgical interventions might include anterior or posterior colporrhaphy (to repair a cystocele or rectocele) and vaginal hysterectomy (for uterine prolapse). An anterior and posterior colporrhaphy may be effective for a first-degree prolapse. This surgical procedure tightens the anterior and posterior vaginal wall, thus repairing a cystocele or rectocele. The pubocervical fascia (supportive tissue between the vagina and bladder) is folded and sutured to bring the bladder and urethra in proper position (Lazarou & Grigorescu, 2011). A vaginal hysterectomy is the treatment of choice for uterine prolapse because it removes the prolapsed organ

that is bringing down the bladder and rectum with it. It can be combined with an anterior and posterior repair if a cystocele or rectocele is present.

Nursing Assessment Nursing assessment for women with POP includes a thorough health history, a physical examination, and several laboratory and diagnostic tests.

Health History and Clinical Manifestations The cause of prolapse is multifactorial, with vaginal childbirth, advancing age, heavy work, poor nutrition, and increasing body mass index being the most consistent risk factors (Walker & Gunasekera, 2011). Assessment of risk factors (chronic straining, hysterectomy, normal aging, and abnormalities of connective tissue) in the woman’s history will assist the health care provider in the diagnosis and treatment of POP. The history should include questions about: • The woman’s obstetrical history (number of pregnancies, weight of newborns, pregnancy spacing) • Chronic respiratory condition (chronic coughing) • Menopausal status • Weight history (loss or gain) • Constipation (frequency and chronicity) • Age • Work history (e.g., physical labor or light office work) • Nutritional assessment • Family history (family member with POP) • Urinary incontinence • Previous pelvic surgeries Assess for clinical manifestations of POP. POP is often asymptomatic, but when symptoms do occur, they are often related to the site and type of prolapse. Symptoms common to all types of prolapses are a feeling of dragging, a lump in the vagina, or something “coming down.” Women with POP can present either with one symptom, such as vaginal bulging or pelvic pressure, or with several complaints, including many bladder, bowel, and pelvic symptoms. Symptoms associated with POP are summarized in Box 7.1. Women present with varying degrees of uterine descent. Uterine prolapse is the most troubling type of pelvic relaxation because it is often associated with concomitant defects of the vagina in the anterior, posterior, and lateral compartments (Lazarou & Grigorescu, 2011).

Physical Examination The pelvic examination performed by the health care provider includes an external genital inspection to visualize any obvious protrusion of the uterus, bladder,

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has more than 100 mL of retained urine, she should be referred for further urodynamic evaluation and testing.

SYMPTOMS ASSOCIATED WITH PELVIC ORGAN PROLAPSE

Laboratory and Diagnostic Tests

• Urinary symptoms • Stress incontinence • Frequency (diurnal and nocturnal) • Urgency and urge incontinence • Hesitancy • Poor or prolonged stream • Feeling of incomplete emptying • Bowel symptoms • Difficulty with defecation • Incontinence of flatus or liquid or solid stool • Urgency of defecation • Feeling of incomplete evacuation • Rectal protrusion or prolapse after defecation • Sexual symptoms • Inability to have frequent intercourse • Dyspareunia • Lack of satisfaction or orgasm • Incontinence during sexual activity • Other local symptoms • Pressure or heaviness in the vagina • Pain in the vagina or perineum • Low back pain after long periods of standing • Palpable bulge in the vaginal vault • Difficulty walking due to a protrusion from the vagina • Difficulty inserting or keeping a tampon in place • Vaginal-cervical mucosa hypertrophy, excoriation, ulceration, and bleeding • Abdominal pressure or pain Adapted from Brubaker, L., Rickey, L., Xu, Y., Markland, A., Lemack, G., Ghetti, C., . . . Stoddard, A. (2010). Symptoms of combined prolapse and urinary incontinence in large surgical cohorts. Obstetrics and Gynecology, 115(2, Pt 1), 310–316; and Lazarou, G., & Grigorescu, B. A. (2011). Pelvic organ prolapse. eMedicine. Retrieved from http://emedicine.medscape.com/article/276259-overview.

urethra, or vaginal wall occurring at the vaginal opening. Usually the woman is asked to perform the Valsalva maneuver (bearing down) while the examiner notes which organ prolapses first and the degree to which it occurs. Any urine leakage during the examination is important to note. The woman is asked to contract the pubococcygeal muscles (Kegel exercise); the health care provider inserts two fingers into the vagina to assess the strength and symmetry of the contraction. Because pelvic or genital organ prolapse can cause urinary symptoms such as incontinence, bladder function should be assessed by determining postvoid residual with a catheter. If the woman

Common laboratory tests that may be ordered to determine the cause of POP include a urinalysis to rule out a bacterial infection, urine culture to identify the specific organism if present, visualization of urine loss during the pelvic examination, and measurement of postvoid urine volume.

Nursing Management Help the woman understand the nature of the condition, the treatment options, and the likely outcomes. Nursing considerations might include the following: • Describe normal anatomy and causes of pelvic prolapse. • Assess how this condition has affected the woman’s life. • Outline the options, with the advantages and disadvantages of each. • Allow the client to make the decision that is right for her. • Provide education. • Schedule preoperative activities needed for surgery. • Reassure the client that there is a solution for her symptoms. • Provide community education about genital prolapse. Nursing Care Plan 7.1 provides an overview of care for a woman with POP.

Encourage Pelvic Floor Muscle Training Encourage the woman to perform Kegel exercises daily (Teaching Guidelines 7.1). Discuss current research findings and educate the woman about estrogen therapy, allowing the woman to make her own decision on whether to use hormones. Controversy still exists regarding the benefits versus the risks of taking hormones, so the woman must weigh this option carefully (Mac Bride, Rhodes, & Shuster, 2010).

Encourage Dietary and Lifestyle Modifications Instruct clients to increase dietary fiber and fluids to prevent constipation. A high-fiber diet with an increase in fluid intake alleviates constipation by increasing stool bulk and stimulating peristalsis. It is accomplished by replacing refined, low-fiber foods with high-fiber foods. The recommended daily intake of fiber for women is 25 g (Dudek, 2010). In addition to increasing the amount of fiber in her diet, also encourage the woman to drink eight 8-oz glasses of fluid daily and to engage in regular low-impact aerobic exercise, which promotes muscle tone and stimulates peristalsis.



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NURSING CARE PLAN 7.1

Overview of a Woman with Pelvic Organ Prolapse (POP) Katherine, a 62-year-old multiparous woman, came to her gynecologist with complaints of a chronic dragging or heavy painful feeling in her pelvis, lower backache, constipation, and urine leakage. Her symptoms increase when she stands for long periods. She has not had menstrual cycles for at least a decade. She tells you, “I’m not taking any of those menopausal hormones.” NURSING DIAGNOSIS: Pain related to relaxation of pelvic support and elimination difficulties Outcome Identification and Evaluation

The client will report an acceptable level of discomfort within 1 to 2 hours of intervention as evidenced by a rating of less than 4 on a 0-to-10 pain scale. Interventions: Providing Pain Management

• Obtain a thorough pain history, including ongoing pain experiences, methods of pain control used, what worked, what didn’t, any allergies to pain medications, and the effect of pain on her activities of daily living to provide a baseline and enable a systematic approach to pain management. • Assess the location, frequency, severity, duration, precipitating factors, and aggravating/alleviating factors to identify characteristics of the client’s pain to plan appropriate interventions. • Educate client about any medications prescribed (correct dosage, route, side effects, and precautions) to increase the client’s understanding of the therapy and promote compliance.

• Assess problematic elimination patterns to identify underlying factors from which to plan appropriate prevention strategies. • Encourage client to increase fluids and fiber in diet and increase physical activity daily to promote peristalsis. • Assist client with establishing regular toileting patterns by setting aside time daily for bowel elimination to promote regular bowel function and evacuation. • Urge client to avoid the routine use of laxatives to reduce risk of compounding constipation.

NURSING DIAGNOSIS: Knowledge deficit related to causes of structural disorders and treatment options Outcome Identification and Evaluation

The client will demonstrate an understanding of current condition and treatments as evidenced by identifying treatment options, making health-promoting lifestyle choices, verbalizing appropriate health care practices, and adhering to treatment plan. Interventions: Providing Client Education

• Assess client’s understanding of pelvic organ prolapse and its treatment options to provide a baseline for teaching. • Review information provided about surgical procedures and recommendations for healthy lifestyle, obtaining feedback frequently, to validate client’s understanding of instructions. • Discuss association between uterine, bladder, and rectal prolapse and symptoms to help client understand the etiology of her symptoms and pain. • Have client verbalize and discuss information related to diagnosis, surgical procedure, preoperative routine, and postoperative regimen to ensure adequate understanding and provide time for correcting or clarifying any misinformation or misconceptions. (continued)

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NURSING CARE PLAN 7.1

Overview of a Woman with Pelvic Organ Prolapse (POP)

(continued)

• Provide written material with pictures to promote learning and help client visualize what has occurred to her body secondary to aging, weight gain, childbirth, and gravity. • Discuss pros and cons of hormone replacement therapy, osteoporosis prevention, and cardiovascular events common in postmenopausal women to promote informed decision making by the client about available menopausal therapies. • Inform client about the availability of community resources and make appropriate referrals as needed to provide additional education and support. • Document details of teaching and learning to allow for continuity of care and further education, if needed.

Teaching Guidelines 7.1 PERFORMING KEGEL EXERCISES • Squeeze the muscles in your rectum as if you are trying to prevent passing flatus. • Stop and start urinary flow to help identify the pubococcygeus muscle. • Tighten the pubococcygeus muscle for a count of three, and then relax it. • Contract and relax the pubococcygeus muscle rapidly 10 times. • Try to bring up the entire pelvic floor and bear down 10 times. • Repeat Kegel exercises at least five times daily.

Educate the client about other lifestyle changes that will assist with prolapse, such as: • Achieve ideal weight to reduce intra-abdominal pressure and strain on pelvic organs, including pressure on the bladder. • Wear a girdle or abdominal support to support the muscles surrounding the pelvic organs. • Avoid lifting heavy objects to reduce the risk of increasing intra-abdominal pressure, which can push the pelvic organs downward. • Avoid high-impact aerobics, jogging, or jumping repeatedly to minimize the risk of increasing intra-­ abdominal pressure, which places downward pressure on the organs. • Give up smoking to minimize the risk for a chronic “smoker’s cough,” which increases intra-abdominal pressure and forces the pelvic organs downward.

Provide Teaching for Pessary Use Educate the woman about pessary use. Discuss complications as part of the instruction. Although the pessary

is a safe device, it is still a foreign body in the vagina. Because of this, the most common side effects of the pessary are increased vaginal discharge, urinary tract infections, vaginitis, and odor. Odors can be reduced ­ by douching with dilute vinegar or hydrogen peroxide. Postmenopausal women with thin vaginal mucosa are susceptible to vaginal ulceration with the use of a pessary. Advise the woman to use estrogen cream to make the vaginal mucosa more resistant to erosion and to strengthen the vaginal walls. The woman must be capable of managing use of the pessary, either alone or with the help of a caretaker. The most common recommendations for pessary care include removing the pessary twice weekly and cleaning it with soap and water; using a lubricant for insertion; and having regular follow-up examinations every 6 to 12  months after an initial period of adjustment. Besides cleaning, clients must properly reinsert the device into their vaginal cavity, and the woman must also be willing to participate in all aspects of care of the pessary for this treatment option to be successful. All women choosing this option must be instructed in the care of her pessary so she feels comfortable with all aspects of it before leaving the health care facility. Health care visits should allow adequate time for women to share their concerns, anxieties, and fears surrounding the transition to life with a pessary.

Provide Perioperative Care Prepare the woman for surgery by reinforcing the risks and benefits of surgery and describing the postoperative course. Explain that a Foley catheter will be in place for up to 1 week, and that she might not be able to urinate due to the swelling after the catheter has been removed. Provide home care instructions for the Foley catheter. She should cleanse the perineal area daily



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with mild soap and water, especially around where the catheter enters the urinary meatus. If the woman is provided with a leg bag to be worn during waking hours, instruct her to empty it frequently and keep it below the level of the bladder to prevent backflow. The same principles are applied to the primary Foley bag when emptying it. During the recovery period, instruct the client to avoid for several weeks activities that cause an increase in abdominal pressure, such as straining, sneezing, and coughing. In addition, advise her to avoid lifting anything heavy or straining to push anything. Explain to the woman that stool softeners and gentle laxatives might be prescribed to prevent constipation and straining with bowel movements. Pelvic rest will be prescribed until the operative area is healed in 6 weeks.

Promote Prevention Strategies Limited data are available on ways to prevent POP. Approaches include lifestyle changes that reduce modifiable risk factors, such as losing weight, avoiding heavy lifting, and relieving constipation. Explore with the woman what factors in her lifestyle might be modified to reduce her risk of developing POP (primary prevention) or to improve her quality of life after receiving treatment (secondary prevention).

Urinary Incontinence Urinary incontinence (UI) is defined by the International Continence Society (2011) as the involuntary loss of urine that represents a hygienic or social problem to the individual. This disorder affects approximately 15  million women in the United States (Townsend, Curhan, ­ Resnick, & ­ Grodstein, 2010). It has been estimated that 50% of all women experience urinary incontinence at some time in their life, varying in severity from mild to severe (DuBeau, 2011). The psychosocial costs and morbidities are even more difficult to quantify. Embarrassment and depression are common. The affected individual may experience a decrease in social interactions, excursions out of the home, and sexual activity (Vasavada, Carmel, & Rackley, 2011). It is more common than diabetes and Alzheimer’s disease, both of which receive a great deal of press attention. D ­ espite the considerable impact of incontinence on quality of life, many women are unlikely to bring up the subject of their lack of bladder control and very few women seek help or treatment for incontinence concerns. The following are several possible explanations for why clients do not talk about their bladder control issues: • The client may feel that UI is inevitable and not amenable to treatment.

• The client may feel that UI is a “normal” part of aging. • The client may believe that UI is part of being “female.” Women tend to “accept” urinary symptoms such as UI more so than men. • The client may consider a UI a hygiene problem and not a medical condition.

Take Note! I ncontinence is preventable, treatable, and often curable. However, many women believe that loss of bladder function is a normal and expected part of aging. Incontinence can have far-reaching effects. Some women experience anxiety, depression, social isolation, and disruptions in their self-esteem and dignity. UI can cause the woman to stop working, traveling, socializing, and enjoying sexual relationships. In addition, incontinence can create a tremendous burden for caretakers and is a common reason for admission to a long-term care facility (Tamanini, Santos, Lebrão, Duarte, & Laurenti, 2011). Women often try to cope with urinary incontinence through lifestyle modifications such as wearing protective pads, avoiding certain activities, emptying the bladder frequently, and modifying diet/fluid intake. Women who experience urinary incontinence are generally most distressed by the social implications and many go to great efforts to hide their symptoms. In some cultures, UI is abhorred to the point where women are shunned by their communities. A sense of control, normality, and self-esteem are central issues in living with UI. Generally with time and a worsening of symptoms, women pursue medical evaluation and treatment (Vasavada et al., 2011). The three most common types of incontinence are urge incontinence (overactive bladder caused by detrusor muscle contractions), stress incontinence (inadequate urinary sphincter function), and mixed incontinence (involves both stress and urge incontinence) (Botlero, Davis, Urquhart, & Bell, 2011). Comparison Chart 7.1 ­ ­details these types of UI.

Pathophysiology and Etiology Urinary continence requires several factors, including effective functioning of the bladder, adequate pelvic floor muscles, neural control from the brain, and integrity of the neural connections that facilitate voluntary control. The bladder neck and proximal urethra function as a sphincter. During urination the sphincter relaxes and the bladder empties. The ability to control urination requires the integrated function of numerous components of the lower urinary tract, which must be structurally sound and functioning normally. Incontinence can develop if the bladder muscles become overactive due to weakened sphincter muscles, if the

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COMPARISON CHART 7.1

URGE INCONTINENCE VS. STRESS INCONTINENCE

Urge Incontinence

Stress Incontinence

Description

Precipitous loss of urine, preceded by a strong urge to void, with increased bladder pressure and detrusor contraction

Accidental leakage of urine that occurs with increased pressure on the bladder from coughing, sneezing, laughing, or physical exertion

Etiology

Causes might be neurologic, idiopathic, or infectious

Develops commonly in women in their 40s and 50s, usually as the result of weakened muscles and ligaments in the pelvis following childbirth

Signs and Symptoms

Urgency, frequency, nocturia, and a large amount of urine loss

Involuntary loss of a small amount of urine in response to physical activity that raises intra-abdominal pressure

bladder muscles become too weak to contract properly, or if signals from the nervous system to the urinary structures are interrupted. A major factor in women that contributes to urinary continence is the estrogen level, because this hormone helps maintain bladder sphincter tone. In perimenopausal or menopausal women, incontinence can be a problem as estrogen levels begin to decline and genitourinary changes occur. In simple terms, the bladder is the reservoir, the urethra is the seal, and the levator ani muscle is the gate that holds pressure against the outflow of urine by supporting the urethra and bladder from below. When any of these three structures is not functioning normally, incontinence occurs. Contributing factors in urinary incontinence include: • Fluid intake, especially alcohol, carbonated drinks, and caffeinated beverages • Constipation: alters the position of the pelvic organs and puts pressure on the bladder • Habitual “preventive” emptying: may result in training the bladder to hold only small amounts of urine • Menopause and depletion of estrogen • Chronic disease such as stroke, multiple sclerosis or diabetes • Smoking: nicotine increases detrusor muscle contractions • Advancing age: age-related anatomic changes provide less pelvic support • Pregnancy and childbirth: damage to pelvic structures during childbirth • Obesity: increases abdominal pressure (Schuiling & L­ ikis, 2011)

Therapeutic Management Treatment options depend on the type of urinary incontinence. In general, the least invasive procedure with the fewest risks is the first choice for treatment. Surgery is used only if other methods have failed. There is a

widespread belief that urinary incontinence is an inevitable problem of getting older and that little or nothing can be done to relieve symptoms or reverse it. Nothing is further from the truth, and attitudes must change so that women will feel comfortable seeking help for this embarrassing condition. For many women with urge incontinence, simple reassurance and lifestyle interventions might help. However, if more than simple lifestyle measures are needed, effective treatments might include: • Bladder training to establish normal voiding intervals (every 3 to 5 hours) • Kegel exercises to strengthen the pelvic floor musculature • Pessary ring to support pelvic structures that have weakened • Pharmacotherapy to reduce the urge to void. Anticholinergic agents such as oxybutynin (Ditropan) or tolterodine (Detrol) might be prescribed. The most common side effects of anticholinergic agents are dry mouth, blurred vision, constipation, nausea, dizziness, and headaches (Kuhn, 2010). For women with stress incontinence, treatment is not always a cure, but it can minimize the impact of this condition on the woman’s quality of life. Some treatment options for stress incontinence might include: • Weight loss if needed • Avoidance of constipation • Smoking cessation • Kegel exercises to strengthen the pelvic floor • Pessaries • Weighted vaginal cones to improve the tone of pelvic floor muscles • Periurethral injection (injecting a bulking agent [collagen] to form a bulge that brings the urethral walls closer together to achieve a better closure)



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• Medications such as duloxetine (Cymbalta, Yentreve) to increase urethral sphincter contractions during the storage phase of the urination cycle • Estrogen replacement therapy to improve bladder sphincter tone • Surgery to correct genital prolapse and improve urethral and bladder tone

and may have an impact on diagnosis and treatment. A rectal examination is done to evaluate sphincter tone and perineal sensation. A urinalysis is performed to look for hematuria, pyuria, glucosuria, or proteinuria. A urine culture is done if there is pyuria or bacteriuria. Postvoid residual should be measured either with pelvic ultrasound or directly with a catheter. If the residual exceeds the limit set, urodynamic testing is then used to diagnose the incontinence.

Nursing Management

L

Consider This

ife can be complicated and embarrassing at times when we least expect it. I met a man in church who seemed interested in me, and he asked me out for coffee after Sunday services. I have been alone for 10 years and this prospect seemed exciting to me. We talked for hours over coffee and seemed to have a great deal in common, especially since both of us had lost our spouses to cancer. He asked me to go square dancing with him, since that was an activity we both had enjoyed in the past with our spouses. I hadn’t been out or physically active for ages and didn’t realize how my body had changed with age. It was during the first dance that I noticed a wet sensation between my legs, which I was unable to control. I managed to continue on and pretend that all was fine, but then realized what many of my friends were talking about—stress incontinence. Not being able to control one’s urine is very embarrassing and it complicates your life, but I made up my mind that it wasn’t going to control me! Thoughts: Gravity and childbirth take a toll on women’s reproductive organs by pushing them downward. This woman is not going to let stress incontinence curtail her outside activity, which demonstrates a good attitude. What can be done about her embarrassing accidents? Were there any preventive strategies she could have used at an earlier age?

Nursing Assessment The assessment of the woman experiencing urinary incontinence includes a history, physical examination, laboratory tests, and possibly urodynamic testing. The onset, frequency, severity, and pattern of incontinence should be determined, as well as any associated symptoms such as frequency, dysuria, urgency, and nocturia. Incontinence may be quantified by asking the woman if she wears a pad and how often the pad is changed. A review of the woman’s current medications, including over-thecounter medications, should be included in the history. A complete physical examination should be carried out by the health care provider; it should include a neurologic assessment and pelvic and rectal examinations. The presence of associated POP should be noted because it can contribute to the woman’s voiding problems

Incontinence can be devastating and can cause psychosocial concerns and isolation. Nurses can encourage women with troublesome symptoms to seek help. Discuss the treatment options with the client, including benefits and potential outcomes, and encourage her to select the continence treatment best for her lifestyle. Provide education about good bladder habits and strategies to reduce the incidence or severity of incontinence (Teaching Guidelines 7.2). Provide support and encouragement to ensure compliance. Remember that aging can increase the risk of incontinence, but incontinence is not an inevitable part of aging. Review the anatomy and physiology of the urinary system and offer simple explanations to help the woman cope with urinary alterations. Therapeutic listening is important. Be aware of the courage it takes for a woman to disclose an embarrassing condition.

Teaching Guidelines 7.2 MANAGING URINARY INCONTINENCE • Avoid drinking too much fluid (i.e., 1.5 L total daily limit), but do not decrease your intake of fluids. • Reduce intake of fluids and foods that are bladder irritants and precipitate urgency, such as chocolate, caffeine, sodas, alcohol, artificial sweetener, hot spicy foods, orange juice, tomatoes, and watermelon. • Increase fiber and fluids in your diet to reduce constipation. • Control blood glucose levels to prevent polyuria. • Treat chronic cough. • Remove any barriers that delay you from reaching the toilet. • Practice good perineal hygiene by using mild soap and water. Wipe from front to back to prevent urinary tract infections. • Become aware of adverse drug effects. • Take your medications as prescribed. • Continue to do pelvic floor (Kegel) exercises. Adapted from Gomelsky, A., & Dmochowski, R. (2011). Treatment of mixed urinary incontinence in women. Current Opinion in Obstetrics & Gynecology, 23(5), 371–375; and Vasavada, S. P., Carmel, M. E., & Rackley, R. (2011). Urinary incontinence. eMedicine. Retrieved from http://emedicine.medscape.com/article/452289-overview.

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Take Note! Simple diet and lifestyle alterations, combined with a proper pelvic floor muscle strengthening program, can often produce significant improvements for women of all ages.

BENIGN GROWTHS The most common benign growths of the reproductive tract include cervical, endocervical, and endometrial polyps; uterine fibroids (leiomyomas); genital fistulas; ­Bartholin’s cysts; and ovarian cysts.

Polyps Polyps are small, usually benign growths. The incidence of malignancy in cervical polyps is 1 in 1,000. Malignancy is more common in perimenopausal or postmenopausal women (Casey, Long, & Marnach, 2011). The cause of polyp growth is not well understood, but they are frequently the result of infection. Polyps might be associated with chronic inflammation, an abnormal local response to increased levels of estrogen, or local congestion of the cervical vasculature (Avolio, 2011). Single or multiple polyps might occur. They are most common in multiparous women. Polyps can appear anywhere but are most common on the cervix and in the uterus (Fig. 7.3). Cervical polyps often appear after menarche. They occur in 2% to 5% of women, and approximately 2% of these polyps have cancerous changes (Schuiling & Likis, 2013).

Endocervical polyps are commonly found in multiparous women ages 40 to 60. Endocervical polyps are more common than cervical polyps, with a stalk of varied width and length. Endometrial polyps are benign tumors or localized overgrowths of the endometrium. Most endometrial polyps are solitary, and they rarely occur in women younger than 20 years of age. The incidence of these polyps rises steadily with increasing age, peaks in the fifth decade of life, and gradually declines after menopause. They are present in up to 25% of women being seen for abnormal bleeding (Nguyen, 2011).

Therapeutic Management Treatment of polyps usually consists of simple removal with small forceps done on an outpatient basis, removal during hysteroscopy, or dilation and curettage (D&C). The polyp base can be removed by laser vaporization. Because many polyps are infected, an antibiotic may be ordered after removal as a preventive measure or to treat early signs of infection. Although polyps are rarely cancerous, a specimen should be sent after surgery to a pathology laboratory to exclude malignancy. A cervical biopsy typically reveals mildly atypical cells and signs of infection. Polyps rarely return after they are removed. Regularly scheduled Pap smears are suggested for women with cervical polyps to detect any future abnormal growths that may be malignant.

Nursing Assessment Nursing assessment for a woman with polyps includes assisting with the physical examination and preparing the collected specimen to be sent to the cytologist.

Clinical Manifestations

Endometrial

Endocervical

Cervical

FIGURE 7.3 Cervical, endocervical, and endometrial polyps.

Assess for clinical manifestations of polyps. Most endocervical polyps are cherry red, whereas most cervical polyps are grayish-white (Nguyen, 2011). Cervical and endocervical polyps are often asymptomatic, but they can produce mild symptoms such as abnormal vaginal bleeding (after intercourse or douching, between menses) or discharge. The most common clinical manifestation of endometrial polyps is metrorrhagia (irregular, acyclic uterine bleeding).

Physical Examination and Laboratory and Diagnostic Studies Typically, cervical polyps are diagnosed when the cervix is visualized through a speculum during the woman’s annual gynecologic examination (Casey et al., 2011). Endometrial polyps are not detected on physical examination, but rather with ultrasound or hysteroscopy (introduction



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of a small camera through the cervix to visualize the uterine cavity).

Nursing Management Nursing management of polyps involves explaining the condition and the rationale for removal and giving follow-up care instructions. The nurse also assists the health care provider with the removal procedure.

Uterine Fibroids Uterine fibroids, or leiomyomas, are benign tumors composed of smooth muscle and fibrous connective tissue in the uterus. Unlike cancerous tumors, fibroids usually grow slowly and their cells do not break away and invade other parts of the body. Fibroids are classified according to their position in the uterus (Fig. 7.4): • Subserosol fibroids: lie underneath the outermost “peritoneal” layer of the uterus and grow out toward the pelvic cavity • Intramural fibroids: grow within the wall of the uterus and are the most common type • Submucosal fibroids: grow from immediately below the inner uterine surface into the uterine cavity (­ Wilson, 2011) Fibroids are estrogen dependent and thus grow rapidly during the childbearing years, when estrogen is plentiful,

Subserosal

Intramural

Submucosal

FIGURE 7.4 Submucosal, intramural, and subserosal fibroids.

but they shrink during menopause, when estrogen levels decline. It is believed that these benign tumors develop in up to 70% of all women over 30 years of age, but up to 50% are asymptomatic (Laughlin & ­Stewart, 2011). It is difficult to be precise because fibroids may cause no symptoms, and thus many women do not know they have them. Fibroids are the most common indication for hysterectomy in the United States. The peak incidence occurs around age 45, and they are three times more prevalent in African American women than Caucasian women (Laughlin & Stewart, 2011).

Etiology Although the cause of fibroids is unknown, several predisposing factors have been identified, including: • Age (late reproductive years) • Genetic predisposition • African American ethnicity • Hypertension • Nulliparity • Obesity (Alexander, LaRosa, Bader, & Garfield, 2010)

Therapeutic Management Treatment depends on the size of the fibroids and the woman’s symptoms. Several treatment options exist, ranging from watchful waiting to surgery.

Medical Management The goals of medical therapy are to reduce symptoms and to reduce the tumor size. This can be accomplished with gonadotropin-releasing hormone (GnRH) agonists such as leuprolide (Lupron), nafarelin (Synarel), or goserelin (Zoladex), which stop ovulation and the production of estrogen, or low-dose mifepristone, a progestin antagonist. Both have produced regression and reduced the size of the tumors without surgery, but long-term therapy is expensive and not tolerated by most women. The side effects of GnRH medications include hot flashes, headaches, mood changes, vaginal dryness, musculoskeletal malaise, bone loss, and depression (King & Brucker, 2011). Long-term mifepristone therapy can result in endometrial hyperplasia, which increases the risk of endometrial malignancy. Once either therapy is stopped, the fibroids typically recur. Uterine artery embolization (UAE) is an option in which polyvinyl alcohol pellets are injected into selected blood vessels via a catheter to block circulation to the fibroid, causing it to shrink and producing symptom resolution. The procedure is carried out by a radiologist who makes a tiny incision in the groin, introduces a fine catheter into the main artery leading to the uterus, and injects tiny particles of plastic or gelatin sponge into the artery that supplies blood to the fibroid. These particles

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stop the flow of blood, causing the fibroid to shrink or disappear completely over time. UAE has short-term ­advantages over surgery. Over the mid and long term, the benefits were similar, except for a higher reintervention rate after UAE (van der Kooij, Bipat, Hehenkamp, Ankum, & ­Reekers, 2011). There remains a need for a treatment that is noninvasive and that preserves fertility.

Surgical Management For women with large fibroids or severe menorrhagia, surgery is preferred over medical treatment. Surgical management might involve myomectomy, laser surgery, or hysterectomy. Myomectomy involves removing the fibroid alone. A myomectomy is performed via laparoscopy, through an abdominal incision or through a vaginal approach. The advantage is that only the fibroid is removed; fertility is not jeopardized because this procedure leaves the uterine muscle walls intact. Myomectomy relieves symptoms but does not affect the underlying process; thus, fibroids grow back and further treatment will be needed in the future. Laser surgery (or electrocauterization) involves destroying small fibroids with lasers. Laser therapy can be done using a vaginal approach or laparoscopically. The laser treatment preserves the uterus, but the process may cause scarring and adhesions, thus impairing fertility (Uterine Fibroids, 2012). Fibroids can return after this procedure. Controversy remains as to whether laser treatment weakens the uterine wall and thus may contribute to uterine rupture in the future. A hysterectomy is the surgical removal of the uterus. After cesarean section, it is the second most frequently performed surgical procedure for women in the United States. Approximately 600,000 hysterectomies are performed annually in the United States (Centers for Disease Control and Prevention [CDC], 2010). The top three conditions associated with hysterectomies are fibroids, endometriosis, and uterine prolapse (CDC, 2010). A hysterectomy to remove fibroids eliminates both the symptoms and the risk of recurrence, but it also terminates the woman’s ability to bear children. Three types of hysterectomy surgeries are available: vaginal hysterectomy, laparoscopically assisted vaginal hysterectomy, and abdominal hysterectomy. In a vaginal hysterectomy, the uterus is removed through an incision in the posterior vagina. Advantages include a shorter hospital stay and recovery time and no abdominal scars. Disadvantages include a limited operating space and poor visualization of other pelvic organs. In a laparoscopically assisted vaginal hysterectomy, the uterus is removed through a laparoscope, through which structures within the abdomen and pelvis are visualized. Small incisions are made in the abdominal wall to permit the laparoscope to enter the surgical site.

Advantages include a better surgical field, less pain, lower cost, and a shorter recovery time. Disadvantages include potential injury to the bladder and the inability to remove enlarged uteruses and scar tissue. In an abdominal hysterectomy, the uterus and other pelvic organs are removed through an incision in the abdomen. This procedure allows the surgeon to visualize all pelvic organs and is typically used when a m ­ alignancy is suspected or a very large uterus is present. Disadvantages include the need for general anesthesia, a longer hospital stay and recovery period, more pain, higher cost, and a visible scar on the abdomen. A summary of treatment options for uterine fibroids is presented in Table 7.1.

Nursing Assessment Nursing assessment for the woman with uterine fibroids includes a thorough health history, physical examination, and laboratory and diagnostic studies.

Health History and Clinical Manifestations The history should include questions about the woman’s menstrual cycle, including alterations in the menstrual pattern (e.g., pain or pressure, aggravating and alleviating factors), history of infertility, and any history of spontaneous abortion, which might indicate a space-­ occupying uterine lesion. Ask if any female relatives have had fibroids, because there is a familial predisposition. Assess for clinical manifestations of uterine fibroids. Symptoms of fibroids depend on their size and location and may include: • Chronic pelvic pain • Low back pain • Iron-deficiency anemia secondary to bleeding • Bloating • Constipation • Infertility (with large tumors) • Dysmenorrhea • Miscarriage • Sciatica • Dyspareunia • Urinary frequency, urgency, incontinence • Irregular vaginal bleeding (menorrhagia) • Feeling of heaviness in the pelvic region

Physical Examination and Laboratory and Diagnostic Studies The bimanual examination performed by the health care provider typically shows an enlarged, irregular uterus. The uterus may be palpable abdominally if the fibroid is very large. Ultrasound may be used to confirm the diagnosis.



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­

TABLE 7.1

SUMMARY OF TREATMENT OPTIONS FOR UTERINE FIBROIDS

Method

Advantages

Disadvantages

Hormones

Noninvasive Reduces size of fibroids Symptom improvement

Serious side effects with l­ ong-term use Fibroids regrow when meds stopped

Uterine artery embolization

Minimally invasive Dramatic decrease in symptoms Future fertility possible

Procedure frequently painful Requires radiation and contrast dye Permanently implanted material Possible negative fertility impact

Myomectomy

Performed as minor surgery Uterus is preserved

Requires general anesthesia New growth of fibroids occurs

Hysterectomy

Complete removal of fibroids Immediate symptom relief

Requires general anesthesia Major surgery with associated risks Fertility not preserved

Laser surgery

Can be done as an outpatient procedure to destroy small fibroids.

Vaporization process can cause scarring and adhesions, affecting future fertility.

Nursing Management The level of support that nurses can provide women with fibroids depends on the type of treatment offered and her choice of them. Nurses should be able to explain any current treatment options and the implications of a diagnosis of fibroids. Many women have not heard of fibroids previously and need reassurance that they are both common and benign. If medication is prescribed, it is essential to explain the possible side effects and why medication can only be taken for a limited duration. If surgery is selected, verbal and written information about it and the aftercare should be addressed (Box  7.2). A woman undergoing a hysterectomy for the treatment of fibroids often needs special care.

Genital Fistulas Genital fistulas are abnormal openings between a genital tract organ and another organ, such as the urinary tract or the gastrointestinal tract. A fistula can result from a congenital anomaly, surgical complications, Bartholin’s gland abscesses, radiation, or malignancy, but the majority of fistulas that occur worldwide are related to obstetric trauma and female genital cutting (Vasavada & Rackley, 2011). During normal labor, the bladder is displaced upward into the abdomen, and the anterior vaginal wall, the base of the bladder, and  the urethra are compressed between the fetal head and the posterior pubis. When labor is obstructed or prolonged, this

unrelieved compression causes ischemia, which causes pressure necrosis and subsequent fistula formation. Common types of fistulas include: • Vesicovaginal: communication between the bladder and genital tract • Urethrovaginal: communication between the urethra and the vagina • Rectovaginal: communication between the rectum or sigmoid colon and the vagina The direct consequences of this damage include urinary incontinence and fecal incontinence if the rectum is involved. This tragic condition has plagued women since the beginning of history (De Ridder, 2011). Another major cause of genital trauma leading to the development of genital fistulas is female genital cutting. This cultural practice is beginning to receive worldwide attention as part of the international public health agenda to move toward reducing its incidence (Sandy, 2011). This cultural practice will be addressed in detail in Chapter 9.

Therapeutic Management Many small fistulas will heal without treatment, but large fistulas often require surgical repair; surgery may be postponed until the edema or inflammation in the surrounding tissues has dissipated. Surgical repair of fistulas is associated with a high success rate if it is done in a timely manner, but larger fistulas and those of long duration have a poorer prognosis (Vasavada & Rackley, 2011).

242   U N I T 2   Women’s Health Throughout the Life Span BOX 7.2

NURSING INTERVENTIONS FOR A WOMAN UNDERGOING A HYSTERECTOMY Preoperative Care • Instruct the client and her family about the procedure and aftercare. • Provide interventions to reduce anxiety (due to perceived threats to the woman’s self-concept and role functioning) and fear of alteration in body image, complications, and pain. Prepare the woman so she knows what to expect throughout her perioperative experience. Explain postoperative pain management procedures that will be used. Identify the high-risk woman early to reduce her stress. • Teach turning, deep breathing, and coughing before surgery to prevent postoperative atelectasis and respiratory complications such as pneumonia. • Encourage the woman to discuss her feelings. Some women equate their femaleness with their reproductive capability, and loss of the uterus could evoke grieving. • Complete all preoperative orders in a timely manner to allow for rest. Postoperative Care • Provide comfort measures. • Administer analgesics promptly or use a PCA pump. • Administer antiemetics to control nausea and vomiting per order. • Change the client’s linens and gown frequently to promote hygiene. • Change the client’s position frequently and use pillows for support to promote comfort and pain management. • Assess the incision, the dressing, and vaginal bleeding and report if bleeding is excessive (soaking perineal pad within an hour). • Monitor elimination and provide increased fluids and fiber to prevent constipation and straining. • Encourage ambulation and active range-of-motion exercises when in bed to prevent thrombophlebitis and venous stasis. • Monitor vital signs to detect early complications. • Be comfortable discussing sexual concerns with the client. Discharge Planning • Advise the client to reduce her activity level to avoid fatigue, which might inhibit healing. • Advise the client to rest when she is tired and to increase her activity level slowly. • Educate the client on the need for pelvic rest (nothing in the vagina) for 6 weeks. • Instruct the client to avoid heavy lifting or straining for about 6 weeks to prevent an increase in intra-­ abdominal pressure, which could weaken her sutures. • Teach the client the signs and symptoms of infection.

• Advise the woman to take showers instead of tub baths to reduce the risk for infection. • Encourage the client to eat a healthy diet with increased intake of fluids to prevent dehydration and fluid and electrolyte imbalance. • Instruct the client to change her perineal pad frequently to prevent infection. • Explain and schedule follow-up care appointments as needed. • Provide information about community resources for support/help.

Nursing Assessment The history should include questions about any changes in the woman’s urinary and bowel patterns. Assess for common signs and symptoms of fistulas, which are related to the type of fistula. If the opening involves the rectum, feces and flatus will leak through the vagina. If it involves the bladder, urine will leak from the vagina. Depending on the location and size of the fistula, the woman may or may not experience discomfort. The health care provider can detect these abnormal openings through inspection and palpation during the pelvic examination. Diagnostic or laboratory tests are generally not ordered once this condition is found.

Nursing Management Provide guidance and support. Offer information to help the woman learn about her condition and, with appropriate intervention, to improve her quality of life. Begin by making sure the woman understands her anatomy and why she is having such symptoms. Provide a thorough explanation of the treatment options so that she can make an informed decision. Be sensitive to the woman’s feeling of shame and fear about her incontinence; these feelings may be why she delayed seeking treatment. Address all of the woman’s needs, both physical and emotional.

Bartholin’s Cysts A Bartholin’s cyst is a swollen, fluid-filled, sac-like structure that results when one of the ducts of the Bartholin’s gland becomes blocked. The cyst may become infected and an abscess may develop in the gland. The Bartholin’s glands are two mucus-secreting glandular structures with duct openings bilaterally at the base of the labia minora near the opening of the vagina that provide lubrication during sexual arousal. Bartholin’s cysts are the most common cystic growths in the vulva, affecting approximately 2% of women at some time in their life (Wechter, Wu, Marzano, & Haefner, 2011).



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Therapeutic Management Treatment can be conservative or surgical depending on the symptoms, the size of the cyst, and whether it is infected or not. Small asymptomatic cysts do not require treatment. Sitz baths along with analgesics are used to reduce discomfort. Antibiotics are prescribed if the gland is infected. The aim of treatment for a cyst or abscess is to create a fistulous tract from the dilated duct to the outside vulva by incision and drainage (I&D). However, cysts or abscesses tend to return if this option is used. Other treatment options beyond I&D include placement of a Word catheter or a small loop of plastic tubing secured in place to prevent closure and to allow drainage. The use of a carbon dioxide laser to remove the cyst is also possible. After the Word catheter is inserted, the balloon tip is inflated and it is left in place for 4 to 6 weeks. The follow-up of the plastic tubing for removal is in approximately 3 weeks. Both procedures are safe and effective alternatives to surgery (Scott, 2011). Treatment for a pregnant woman with a Bartholin’s cyst depends on the severity of the symptoms and whether an infection is present. Surgery may be delayed until after the woman gives birth if there are no symptoms.

Nursing Assessment Nursing assessment for the woman with a Bartholin’s cyst includes a thorough health history, physical examination, and laboratory and diagnostic tests.

Health History The history should include questions about the woman’s sexual practices and protective measures used. Assess for common signs and symptoms of Bartholin’s cysts. The woman may be asymptomatic if the cyst is small (less than 5 cm) and not infected. If infection is present, symptoms include varying degrees of pain, especially when walking or sitting; unilateral edema; redness around the gland; and dyspareunia. Extensive inflammation may cause systemic symptoms. Abscess formation occurs when the cystic fluid becomes infected. An abscess usually develops rapidly over a 2- to 3-day period and may spontaneously rupture. A history of sudden relief of pain following profuse discharge is highly suggestive of spontaneous rupture (Schuiling & Likis, 2013).

Physical Examination and Laboratory and Diagnostic Studies The diagnosis of Bartholin’s cysts or abscesses is primarily made during a physical examination when a protruding tender labial mass is located. In women over the age of 40, there is an increased risk of malignancy, accounting for 1% to 2% of all invasive vulvar malignancies

(Schecter & Quinn, 2010). Cultures of the purulent abscess fluid and of the cervix should be obtained for Neisseria gonorrhoeae and ­ Chlamydia trachomatis to rule out a sexually transmitted infection.

Nursing Management Nurses must be aware of and knowledgeable about vulvar cysts and treatment options. The woman may be aware of a vulvar cyst secondary to the pain or may be unaware of it if it is asymptomatic. A Bartholin’s cyst may be an incidental finding during a routine pelvic examination. Explain the cause of the cyst and assist with cultures if needed. Provide reassurance and support.

Ovarian Cysts An ovarian cyst is a fluid-filled sac that forms on the ovary (Fig. 7.5). These very common growths are benign 90% of the time and are asymptomatic in many women. Ovarian cysts occur in 30% of women with regular menses, 50% of women with irregular menses, and 7% of postmenopausal women (Helm, 2011). When the cysts grow large and exert pressure on surrounding structures, women often seek medical help.

Types of Ovarian Cysts The most common benign ovarian cysts are follicular cysts, corpus luteum (lutein) cysts, theca-lutein cysts, and polycystic ovarian syndrome (PCOS).

Follicular Cysts Follicular cysts are caused by the failure of the ovarian follicle to rupture at the time of ovulation. Follicular cysts seldom grow larger than 5 cm in diameter; most regress and require no treatment. They can occur at any age but are more common in reproductive-aged women and are rare after menopause. They are detected by vaginal ultrasound.

Corpus Luteum (Lutein) Cysts A corpus luteum cyst forms when the corpus luteum becomes cystic or hemorrhagic and fails to degenerate after 14 days. These cysts might cause pain and delay the next menstrual period. A pelvic ultrasound helps to make this diagnosis. Typically these cysts appear after ovulation and resolve without intervention.

Theca-Lutein Cysts Prolonged abnormally high levels of human chorionic gonadotropin (hCG) stimulate the development of

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Fallopian tube

Fimbriae

Opening of fallopian tube

Semitransparent, distended, fluid-filled cyst

FIGURE 7.5 Ovarian cyst. (Asset provided by Anatomical Chart Co.)

theca-lutein cysts. Although rare, these cysts are associated with hydatidiform mole, choriocarcinoma, polycystic ovary syndrome, and Clomid therapy.

of cases of anovulatory subfertility and up to 20% of couples’ infertility cases (Montplaisir, 2011).

Polycystic Ovary Syndrome

Careful attention should be given to this condition because affected women are at increased risk for long-term health problems such as cardiovascular disease, ­hypertension, dyslipidemia, type 2 diabetes (half of all women), infertility, and cancer (endometrial, breast, and ovarian) (Rachoń & Teede, 2010).

Take Note! Polycystic ovary syndrome (PCOS) involves the presence of multiple inactive follicle cysts within the ovary that interfere with ovarian function. It is a multifaceted disorder, and central to its pathogenesis are hyperandrogenemia and hyperinsulinemia, which are targets for treatment (King & Brucker, 2011). It is associated with obesity, hyperinsulinemia, elevated luteinizing hormone levels (linked to ovulation), elevated androgen levels (virilization), hirsutism (male-pattern hair growth), follicular atresia (ovarian growth failure), ovarian growth and cyst formation, anovulation (failure to ovulate), infertility, type 2 diabetes, sleep apnea, amenorrhea (absence of menstruation or irregular periods), metabolic syndrome, which is characterized by abdominal obesity (waist circumference >35 inches), dyslipidemia (triglyceride level >150 mg/dL, high-density lipoprotein cholesterol level 40 years of age • Epithelial cell abnormalities: • Squamous cell • Atypical squamous cells • Of undetermined significance (ASC-US) • Cannot exclude HSIL (ASC-H) • Low-grade squamous intraepithelial lesion (LSIL) • Encompassing HPV/mild dysplasia/CIN-1 • High-grade squamous intraepithelial lesion (HSIL) • Encompassing moderate and severe dysplasia CIS/CIN-2 and CIN-3 • With features suspicious for invasion • Squamous cell carcinoma • Glandular Cell: Atypical • Endocervical, endometrial, or glandular cells • Endocervical cells—favor neoplastic • Glandular cells—favor neoplastic • Endocervical adenocarcinoma in situ • Adenocarcinoma • Endocervical, endometrial, extrauterine • Other malignant neoplasms (specify) Educational Notes and Suggestions: (optional) Adapted from Healthwise. (2010). The Bethesda ­System. Retrieved from http://health.msn.com/healthtopics/articlepage.aspx?cp-documentid=100069016; National Cancer Institute [NCI]. (2011c). Cervical cancer prevention. Retrieved from http://www.cancer. gov/cancertopics/pdq/prevention/cervical/Patient/ page3#Keypoint11; and Schuiling, K. D., & Likis, F. E. (2011). Women’s gynecologic health (2nd ed.). Sudbury, MA: Jones & Bartlett.

Every 2 years—using liquid-based method Ages 30–70

Every 2–3 years if last three Pap smears were normal

After age 70

May discontinue if: • Past three Pap smears were normal and • No Pap smears in the past 10 years were abnormal

Adapted from American Cancer Society [ACS]. (2011a). American Cancer Society guidelines for the early detection of cancer. Retrieved from http:// www.cancer.org/Healthy/FindCancerEarly/CancerScreeningGuidelines/ american-cancer-society-guidelines-for-the-early-detection-of-cancer.

affected cells as possible. Box  8.2 describes treatment options. Using the Bethesda System, the following management guidelines for abnormal Pap results were ­developed by the NCI to provide direction to health care providers and clients: • ASC-US: Repeat the Pap smear in 4 to 6  months or refer for colposcopy. • ASC-H: Refer for colposcopy with HPV testing. • Atypical glandular cells (AGC) and adenocarcinoma in situ (AIS): Immediate colposcopy; follow-up is based on the findings. Colposcopy is a microscopic examination of the lower genital tract using a magnifying instrument called a colposcope. Specific patterns of cells that correlate well with certain histologic findings can be visualized.

Nursing Assessment Obtain a thorough history and physical examination of  the woman. Investigate her history for risk factors such as: • Early age at first intercourse (within 1 year of menarche) • Lower socioeconomic status • Promiscuous male partners • Unprotected sexual intercourse • Family history of cervical cancer (mother or sisters) • Sexual intercourse with uncircumcised men • Female offspring of mothers who took diethylstilbestrol (DES) • Infections with genital herpes or chronic chlamydia • Multiple sex partners • Cigarette smoking



C h a p t e r 0 8   Cancers of the Female Reproductive Tract    267 BOX 8.2

TREATMENT OPTIONS FOR CERVICAL CANCER • Cryotherapy—destroys abnormal cervical tissue by freezing with liquid nitrogen, Freon, or nitrous oxide. Studies show a 90% cure rate (NCI, 2011b). Healing takes up to 6 weeks, and the client may experience a profuse, watery vaginal discharge for 3 to 4 weeks. • Cone biopsy or conization—removes a coneshaped section of cervical tissue. The base of the cone is formed by the ectocervix (outer part of the cervix) and the point or apex of the cone is from the endocervical canal. The transformation zone is contained within the cone sample. The cone biopsy is also a treatment and can be used to completely remove any precancers and very early cancers. Two methods are commonly used for cone biopsies: • LEEP (loop electrosurgical excision procedure) or LLETZ (large loop excision of the transformation zone)—the abnormal cervical tissue is removed with a wire that is heated by an electrical current. For this procedure, a local anesthetic is used. It is performed in the health care provider’s office in approximately 10 minutes. Mild cramping and bleeding may persist for several weeks after the procedure. • Cold knife cone biopsy—a surgical scalpel or a laser is used instead of a heated wire to remove tissue. This procedure requires general anesthesia and is done in a hospital setting. After the procedure, cramping and bleeding may persist for a few weeks. • Laser therapy—destroys diseased cervical tissue by using a focused beam of high-energy light to vaporize it (burn it off). After the procedure, the woman may experience a watery brown discharge for a few weeks. Very effective in destroying precancers and preventing them from developing into cancers. • Hysterectomy—removes the uterus and cervix surgically • Radiation therapy—delivered by internal radium applications to the cervix or external radiation therapy that includes lymphatics of the pelvis • Chemoradiation—weekly cisplatin therapy concurrent with radiation. Investigation of this therapy is ongoing (ACS, 2011c, 2011e)

• Immunocompromised state • HIV infection • Oral contraceptive use • Moderate dysplasia on Pap smear within past 5 years • HPV infection (CDC, 2011c) Question the woman about any signs and symptoms. Clinically, the first sign is abnormal vaginal bleeding, usually after sexual intercourse. Also be alert for reports of vaginal discomfort, malodorous discharge, and dysuria. In some cases the woman is asymptomatic, with

detection occurring at an annual gynecologic examination and Pap test. Perform a physical examination. Inspect the perineal area for vaginal discharge or genital warts. Perform or assist with a pelvic examination, including the collection of a Pap smear as indicated (Nursing Procedure 8.1).

Take Note! Suspect advanced cervical cancer in women with pelvic, back, or leg pain, weight loss, anorexia, weakness and fatigue, and fractures. Prepare the woman for further diagnostic testing if indicated, such as a colposcopy. In a colposcopy, the woman is placed in the lithotomy position and her cervix is cleansed with acetic acid solution. Acetic acid makes abnormal cells appear white, which is referred to as acetowhite. These white areas are then biopsied and sent to the pathologist for assessment. Although this test is not painful, has minor side effects (minor bleeding, cramping, and a risk of an infection developing after the biopsy), and can be performed safely in the clinic or office setting, women may be apprehensive or anxious about it because it is done to identify and confirm potential abnormal cell growth. Some health care providers request that the woman premedicate with a mild analgesic such as ibuprofen prior to undergoing the procedure. Provide appropriate physical and emotional preparation for this test (Evidence-Based Practice 8.1).

Nursing Management The nurse’s role involves primary prevention by educating women about risk factors and ways to prevent cervical dysplasia. Cervical cancer rates have decreased in the United States because of the widespread use of Pap testing, which can detect precancerous lesions of the cervix before they develop into cancer. Gardasil and Cervarix are vaccines approved by the U.S. Food and Drug Administration to protect girls and women from HPV and thus prevent cervical cancer. The vaccines prevent infection from four HPV types: HPV 6, 11, 16, and 18. Theses types are responsible for 70% of cervical cancers and 90% of genital warts (NCI, 2011c). Clinical trials indicate that the vaccine has high efficacy in preventing persistent HPV infection, cervical cancer precursor lesions, vaginal and vulvar cancer precursor lesions, and genital warts (NCI, 2011c). The vaccine is administered by intramuscular injection, and the recommended schedule is a three-dose series with the second and third doses administered 2 and 6 months after the first dose. The recommended age for vaccination of females is 9 to 26 years old (Association of Women’s Health, Obstetric and Neonatal Nurses, 2010). The vaccines protect against infection with these types of HPV for 6 to 8 years. It is not known if the protection lasts longer. The vaccines

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NURSING PROCEDURE 8.1

Assisting With Collection of a Pap Smear Purpose: To Obtain Cells From the Cervix for Cervical Cytology Screening 1. Explain procedure to the client (Fig. A). 2. Instruct client to empty her bladder. 3. Wash hands thoroughly. 4. Assemble equipment, maintaining sterility of equipment (Fig. B). 5. Position client on stirrups or foot pedals so that her knees fall outward. 6. Drape client with a sheet for privacy, covering the abdomen but leaving the perineal area exposed. 7. Open packages as needed. 8. Encourage client to relax. 9. Provide support to client as the practitioner obtains a sample by spreading the labia; inserting

the speculum; inserting the cytobrush and swabbing the endocervix; and inserting the plastic spatula and swabbing the cervix (Figs. C–H). 10. Transfer specimen to container (Fig. I) or slide. If a slide is used, spray the fixative on the slide. 11. Place sterile lubricant on the practitioner’s fingertip when indicated for the bimanual examination. 12. Wash hands thoroughly. 13. Label specimen according to facility policy. 14. Rinse reusable instruments and dispose of waste appropriately (Fig. J). 15. Wash hands thoroughly.

A

B

C

D



C h a p t e r 0 8   Cancers of the Female Reproductive Tract    269

NURSING PROCEDURE 8.1

(continued)

E

F

G

H

I

J

Used with permission from Klossner, N. J., & Hatfield, N. T. (2009). Introductory maternity and pediatric nursing (2nd ed.). Philadelphia, PA: ­Lippincott Williams & Wilkins.

do not protect women who are already infected with HPV (NCI, 2011c). However, the vaccine is not a substitute for routine cervical cancer screening, and vaccinated women should have Pap smears as recommended. Focus primary prevention education on the following: • Identify high-risk behaviors in clients and teach them how to reduce such behaviors: • Take steps to prevent STIs.

• Avoid early sexual activity. • Faithfully use barrier methods of contraception. • Avoid smoking and drinking. • Receive the HPV vaccine. • Instruct women on the importance of screening for cervical cancer by having annual Pap smears. Outline the proper preparation before having a Pap smear (Teaching Guidelines 8.3). Reinforce specific guidelines for screening.

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EVIDENCE-BASED PRACTICE 8.1

ANXIETY REDUCTION FOR WOMEN UNDERGOING A COLPOSCOPY

STUDY Getting abnormal Pap smear results can be upsetting for a woman. A colposcopy is a follow-up examination that is commonly used to identify these suspicious cells and obtain a specimen for biopsy. A woman’s anxiety about this examination is increased by the possibility of a cancer diagnosis. High levels of anxiety before and during colposcopy can have psychological consequences including pain, discomfort, and failure to return for follow-up. Studies have shown that anxiety can heighten discomfort, so researchers sought to discover which method of preparation for colposcopy best reduces a woman’s anxiety. They conducted a detailed search of databases, clinical trial registers, and protocols to evaluate all randomized and quasi-randomized controlled trials involving interventions to reduce anxiety during colposcopy. Eleven trials involving 1,441 women were identified. The trials compared the anxiety levels of the intervention group with those of a control group. The methods used to reduce anxiety were informational leaflets, counseling, informational videos, video during colposcopy, music, and verbal information.

informational videos, and viewing the video during the procedure. Other methods, such as informational leaflets, counseling, and verbal information, were not found to reduce anxiety vs. control groups. The knowledge provided by the leaflets did not reduce anxiety levels, they did increase knowledge levels and are therefore useful in obtaining clinical consent to the colposcopic procedure. Leaflets also contributed to improved client quality of life by reducing psychosexual dysfunction.

Nursing Implications Nurses can use the information from this study to design appropriate strategies for client teaching and can encourage women to use these measures to reduce anxiety. For example, the nurse can suggest that the client listen to her favorite music during the procedure to help her relax. Nurses can urge women to seek agencies or settings that include these measures as part of their procedure, and nurses can work with their facilities to ensure that music, informational videos, and videotape equipment are available for use during this procedure.­

Findings Three methods were found to significantly reduce anxiety during colposcopy: listening to music, watching Adapted from Galaal, K., Bryant, A, Deane, K.H.O., Al-Khaduri, M., & Lopes, A. D. (2011). Interventions for reducing anxiety in women undergoing colposcopy. Cochrane Database of Systematic Reviews, 2011 (12). doi:10.1002/14651858.CD006013.pub3.

Teaching Guidelines 8.3 STRATEGIES TO OPTIMIZE Pap SMEAR RESULTS • Schedule your Pap smear appointment about 2 weeks (10 to 18 days) after the first day of your last menses to increase the chance of getting the best sample of cervical cells without menses. • Refrain from intercourse for 48 hours before the test because additional matter such as sperm can obscure the specimen. • Do not douche within 48 hours before the test to prevent washing away cervical cells that might be abnormal. • Do not use tampons, birth control foams, jellies, vaginal creams, or vaginal medications for 72 hours before the test, because they could cover up or obscure the cervical cell sample. • Cancel your Pap appointment if vaginal bleeding occurs, because the presence of blood cells interferes with visual evaluation of the sample (Schuiling & L­ ikis, 2013).

Nurses also can advocate for clients by making sure that the Pap smear is sent to an accredited laboratory for interpretation. Doing so reduces the risk of false-­ negative results. Secondary prevention focuses on reducing or limiting the area of cervical dysplasia. Tertiary prevention focuses on minimizing disability or the spread of cervical cancer. Explain in detail all procedures that might be needed. Encourage the client who has undergone any cervical treatment to allow the pelvic area to rest for approximately 1  month. Discuss this rest period with the client and her partner to gain his cooperation. Outline alternatives to vaginal intercourse, such as cuddling, holding hands, and kissing. Remind the woman about any follow-up procedures that are needed and assist her with scheduling if necessary. Throughout the process, provide emotional support to the woman and her family. During the decision-­ making process, the woman may be overwhelmed by the diagnosis and all the information being presented. Refer the woman and her family to appropriate community resources and support groups as indicated. It is crucial for all women to be given correct information regarding



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safe sexual practices, informed about the preventive role of the HPV vaccination, and become educated about the role of the Pap test as a secondary screening measure for cervical cancer. Nurses across all settings are in a powerful position to be advocates for safe health care practices of women through education at personal, community, and national levels.

Vaginal Cancer Vaginal cancer is malignant tissue growth arising in the vagina. Vaginal cancer is rare. Only about 1 of every 100 cancers of the female reproductive system is a vaginal cancer. In 2011, the most recent year for which data are available for vaginal cancer in the United States, the ACS (2011g) estimated that more than 2,500 new cases were diagnosed in women and that about 800 of those women died from this cancer. The peak incidence of vaginal cancer occurs at 60 to 65  years of age. The prognosis of vaginal cancer depends largely on the stage of disease and the type of tumor. The overall 5-year survival rate for squamous cell carcinoma is about 42%; that for adenocarcinoma is about 78% (NCI, 2011f). Vaginal cancer can be effectively treated, and when found early it is often curable.

Pathophysiology The etiology of vaginal cancer has not been identified. Malignant diseases of the vagina are either primary vaginal cancers or metastatic forms from adjacent or distant organs. About 80% of vaginal cancers are metastatic, primarily from the cervix and endometrium. These cancers invade the vagina directly. Cancers from distant sites that metastasize to the vagina through the blood or lymphatic system are typically from the colon, kidneys, skin (melanoma), or breast. Tumors in the vagina commonly occur on the posterior wall and spread to the cervix or vulva (NCI, 2011f). Squamous cell carcinomas (SCCs) that begin in the epithelial lining of the vagina account for about 85% of vaginal cancers. This type of cancer usually occurs in women over age 50. The SCCs develop slowly over a period of years, commonly in the upper third of the vagina. They tend to spread early by directly invading the bladder and rectal walls. They also metastasize through blood and lymphatics. The remaining 15% are adenocarcinomas, which differ from SCC by an increase in pulmonary metastases and supraclavicular and pelvic node involvement (ACS, 2011g).

Therapeutic Management Treatment of vaginal cancer depends on the type of cells involved and the stage of the disease. If the cancer is localized, radiation, laser surgery, or both may be used. If

the cancer has spread, radical surgery might be needed, such as a hysterectomy, or removal of the upper vagina with dissection of the pelvic nodes in addition to radiation therapy.

Nursing Assessment Begin the history and physical examination by reviewing for risk factors. Although direct risk factors for the initial development of vaginal cancer have not been identified, associated risk factors include advancing age (over 60 years old), previous pelvic radiation, exposure to DES in utero, vaginal trauma, history of genital warts (HPV infection), HIV infection, cervical cancer, chronic vaginal discharge, smoking, and low socioeconomic level (ACS, 2011g). Question the woman about any complaints. Most women with vaginal cancer are asymptomatic. Those with symptoms have painless vaginal bleeding (often after sexual intercourse), abnormal vaginal discharge, dyspareunia, dysuria, constipation, and pelvic pain (NCI, 2011f). During the physical examination, observe for any obvious vaginal discharge or genital warts or changes in the appearance of the vaginal mucosa. Anticipate colposcopy with biopsy of suspicious lesions to confirm the diagnosis.

Nursing Management Nursing management for this cancer is similar to that for other reproductive cancers, with emphasis on sexuality counseling and referral to local support groups. Women undergoing radical surgery need intensive counseling about the nature of the surgery, risks, potential complications, changes in physical appearance and physiologic function, and sexuality alterations.

Vulvar Cancer Vulvar cancer is an abnormal neoplastic growth on the external female genitalia (Fig.  8.5). Vulvar cancer accounts for approximately 5% of all female genital malignancies. It occurs in about 1.5 per 100,000 women-years in developed countries. It is the fourth most common gynecologic cancer, after endometrial, ovarian, and cervical cancers (NCI, 2011g). The ACS (2011h) estimated that in 2011, over 4,000 cancers of the vulva were diagnosed in the United States and over 900 women died of this cancer. When detected early, it is highly curable. Vulvar cancer is found most commonly in older women in their mid-60s to mid-70s, but the incidence in women younger than 35 years old has increased during the past few decades. The overall 5-year survival rate when lymph nodes are not involved is 90%, but it drops to 50% to 70% when the lymph nodes have been invaded (ACS, 2011h).

272   U N I T 2   Women’s Health Throughout the Life Span Clitoris Urethral orifice

Vestibule

Vaginal orifice Vulvar lesions

FIGURE 8.5 Vulvar cancer. (The Anatomical Chart Company. [2009]. [3rd ed.]. ­Philadelphia, PA: Lippincott Williams & Wilkins.)

Pathophysiology Approximately 90% of vulvar tumors are squamous cell carcinomas. This type of cancer forms slowly over several years and is usually preceded by precancerous changes. These precancerous changes are termed vulvar intraepithelial neoplasia (VIN). The two major types of VIN are classic (undifferentiated) and simplex (differentiated). Classic VIN, the more common one, is associated with HPV infection (genital warts due to types 16, 18, 31, 33, 35, and 51) and smoking (Dittmer, Fischer, Diedrich, & Thill, 2012). It typically occurs in women between 30 and 40 years old. In contrast to classic VIN, simplex VIN usually occurs in postmenopausal women and is not associated with HPV (Ghebre, Posthuma, Vogel, Geller, & Carson, 2011).

Screening and Diagnosis Annual vulvar examination is the most effective way to prevent vulvar cancer. Careful inspection of the vulva

during routine annual gynecologic examinations remains the most productive diagnostic technique. Liberal use of biopsies of any suspicious vulvar lesion is usually nec­ essary to make the diagnosis and to guide treatment. However, many women do not seek health care evaluation for months or years after noticing an abnormal lump or lesion. The diagnosis of vulvar cancer is made by a biopsy of the suspicious lesion, which is usually found on the labia majora.

Take Note! Vulvar pruritus or a lump is present in the majority of women with vulvar cancer. Lumps should be biopsied even if the woman is asymptomatic.

Therapeutic Management Treatment varies depending on the extent of the disease. Laser surgery, cryosurgery, or electrosurgical incision may be used. Larger lesions may need more extensive



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surgery and skin grafting. The traditional treatment for vulvar cancer has been radical vulvectomy, but more conservative techniques are being used to improve psychosexual outcomes.

Nursing Assessment Typically, no single specific clinical symptom heralds this disease, so diagnosis is often delayed significantly. Therefore, it is important to review the woman’s history for risk factors such as: • Exposure to HPV type 16 • Age over 50 years • HIV infection • VIN • Lichen sclerosus • Melanoma or atypical moles • Exposure to HSV type 2 • Multiple sex partners • Smoking • Herpes simplex • History of breast cancer • Immune suppression • Hypertension • Diabetes mellitus • Obesity (ACS, 2011h) In most cases, the woman reports persistent vulvar itching, burning, and edema that do not improve with the use of creams or ointments. A history of condyloma, gonorrhea, and herpes simplex are some of the factors for greater risk for VIN. Diagnosis of vulvar carcinoma is often delayed. Women neglect to seek treatment for an average of 6 months from the onset of symptoms. In addition, a delay in diagnosis often occurs after the client presents to her physician. In many cases, a biopsy of the lesion is not performed until the problem fails to respond to numerous topical therapies. During the physical examination, observe for any masses or thickening of the vulvar area. A vulvar lump or mass most often is noted. The vulvar lesion is usually raised and may be fleshy, ulcerated, leukoplakic, or warty. The cancer can appear anywhere on the vulva, although about three fourths arise primarily on the labia (Creasman, 2011b). Less commonly, the woman may present with vulvar bleeding, discharge, dysuria, and pain.

Nursing Management Women with vulvar cancer must clearly understand their disease, treatment options, and prognosis. To accomplish this, provide information and establish effective communication with the client and her family. Act as an educator and advocate. Teach the woman about healthy lifestyle behaviors, such as smoking cessation and measures to reduce risk factors. For example, instruct the woman how to examine

her genital area, urging her to do so monthly between menstrual periods. Tell her to look for any changes in appearance (e.g., whitened or reddened patches of skin); changes in feel (e.g., areas of the vulva becoming itchy or painful); or the development of lumps, moles (e.g., changes in size, shape, or color), freckles, cuts, or sores on the vulva. Urge the woman to report these changes to the health care provider (ACS, 2011h). Teach the woman about preventive measures such as not wearing tight undergarments and not using perfumes and dyes in the vulvar region. Also educate her about the use of barrier methods of birth control (e.g., condoms) to reduce the risk of contracting HIV, HSV, and HPV. For the woman diagnosed with vulvar cancer, provide information and support. Discuss potential changes in sexuality if radical surgery is performed. Encourage her to communicate openly with her partner. Refer her to appropriate community resources and support groups. KEY CONCEPTS Women have a one-in-three lifetime risk of developing cancer, and one out of every four deaths is from cancer; thus, nurses must focus on screening and educating all women regardless of risk ­factors. The nurse plays a key role in offering emotional support, determining appropriate sources of support, and helping the woman use effective coping strategies when facing a diagnosis of cancer of the reproductive tract. Although reproductive tract cancer is rare during pregnancy, the woman’s vigilance and routine screenings should continue t­ hroughout. A woman’s sexuality and culture are inextricably interwoven, and it is essential that nurses working with women of various cultures recognize this and remain sensitive to the vast changes that will take place when the diagnosis of cancer is made. Ovarian cancer is the eighth most common cancer among women and the fourth most common cause of cancer deaths for women in the United States, accounting for more deaths than any other cancer of the reproductive system. Ovarian cancer has been described as the “overlooked disease” or “silent killer” because women and health care practitioners often ignore or rationalize early symptoms. It is typically diagnosed in advanced stages. Unopposed endogenous and exogenous estrogens, obesity, nulliparity, menopause after the age of 52 years, and diabetes are the major etiologic risk factors associated with the development of endometrial cancer.

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The American Cancer Society recommends that women should be informed about risks and symptoms of endometrial cancer at the onset of menopause and strongly encouraged to report any unexpected bleeding or spotting to their health care providers. Malignant diseases of the vagina are either primary vaginal cancers or metastatic forms from adjacent or distant organs. Vaginal cancer tumors can be effectively treated and, when found early, are often curable. Cervical cancer incidence and mortality rates have decreased noticeably in the past several decades, with most of the reduction attributed to the Pap test, which detects cervical cancer and precancerous lesions. The nurse’s role involves primary prevention of cervical cancer through education of women regarding risk factors and preventive vaccines to avoid cervical dysplasia. Diagnosis of about 80% of vaginal cancers are metastatic, primarily from the cervix and endometrium. These cancers invade the vagina directly. Vulvar cancer is often delayed significantly because there is no single specific clinical symptom that heralds it. The most common presentation is persistent vulvar itching that does not improve with the application of creams or ointments. References Agency for Healthcare Research and Quality. (2010). Women: Stay healthy at any age—Your checklist for health (AHRQ Publications No. 07-IP005-A). Retrieved from http://www.ahrq. gov/ppip/ healthywom.htm Alexander, L. L., LaRosa, J. H., Bader, H., & Garfield, S. (2010). New dimensions in women’s health (5th ed.). Sudbury, MA: Jones & Bartlett. American Cancer Society [ACS]. (2011a). American Cancer Society guidelines for the early detection of cancer. Retrieved from http://www .cancer.org/Healthy/FindCancerEarly/CancerScreeningGuide​lines/ american-cancer-society-guidelines-for-the-early-detection-of-cancer American Cancer Society [ACS]. (2011b). Cancer facts and figures 2011. Retrieved from http://www.cancer.org/Research/CancerFactsFigures​ /CancerFactsFigures/cancer-facts-figures-2011 American Cancer Society [ACS]. (2011c). Cervical cancer. Retrieved from http://www.cancer.org/Cancer/CervicalCancer/DetailedGuide/ cervical-cancer-key-statistics American Cancer Society [ACS]. (2011d). Endometrial cancer overview. Retrieved from http://www.cancer.org/Cancer/EndometrialCancer/ OverviewGuide/index American Cancer Society [ACS]. (2011e). How are cervical cancers and precancers diagnosed? Retrieved from http://www.cancer.org/ Cancer/CervicalCancer/DetailedGuide/cervical-cancer-diagnosis American Cancer Society [ACS]. (2011f). Ovarian cancer: Survival by stage. Retrieved from http://www.cancer.org/Cancer/OvarianCancer/ DetailedGuide/ovarian-cancer-survival-rates American Cancer Society [ACS] (2011g). Vaginal cancer. Retrieved from http://www.cancer.org/Cancer/VaginalCancer/DetailedGuide/index American Cancer Society [ACS] (2011h). Vulvar cancer. Retrieved from http://www.cancer.org/Cancer/VulvarCancer/DetailedGuide/index American Cancer Society [ACS] (2011i). What are the key statistics about ovarian cancer? Retrieved from http://www.cancer.org/Cancer/ OvarianCancer/DetailedGuide/ovarian-cancer-key-statistics

American College of Obstetricians and Gynecologists [ACOG]. (2011). Committee opinion #483, Primary and preventive care: Periodic assessments. Retrieved from http://www.acog.org/About%20ACOG/ News%20Room/News%20Releases/2011/Routine%20Screening%20 Recommendations%20Released%20for%20Annual%20Well%20 Woman%20Exam.aspx Association of Women’s Health, Obstetric and Neonatal Nurses. (2010). HPV vaccination for the prevention of cervical cancer. Journal of Obstetric, Gynecologic & Neonatal Nursing, 14(1), 129–130. Broadman, C. H., & Matthews, K. J. (2011). Cervical cancer. eMedicine. Retrieved from http://emedicine.medscape.com/article/253513-overview Centers for Disease Control and Prevention [CDC]. (2011a). Addressing the cancer burden at a glance 2011. Retrieved from http://www.cdc .gov/chronicdisease/resources/publications/AAG/dcpc.htm Centers for Disease Control and Prevention [CDC]. (2011b). Cancer prevention and control. Retrieved from http://www.cdc.gov/cancer/ dcpc/prevention/other.htm Centers for Disease Control and Prevention [CDC]. (2011c). Cervical cancer risk factors. Retrieved from http://www.cdc.gov/cancer/ cervical/basic_info/risk_factors.htm Centers for Disease Control and Prevention [CDC]. (2011d). Ovarian cancer. Retrieved from http://www.cdc.gov/cancer/ovarian/ Creasman, W. T. (2011a). Endometrial carcinoma. eMedicine. Retrieved from http://emedicine.medscape.com/article/254083-overview Creasman, W. T. (2011b). Malignant vulvar lesions. eMedicine. Retrieved from http://emedicine.medscape.com/article/264898-overview Dicken, C., Lieman, H., Dayal, A., Mutyala, S., & Einstein, M. (2010). A multidisciplinary approach to fertility-sparing therapy for a rare vulvar tumor. Fertility and Sterility, 93(1), 267–273. Dickerson, S., Alqaissi, N., Underhill, M., & Lally, R. (2011). Surviving the wait: Defining support while awaiting breast cancer surgery. Journal of Advanced Nursing, 67(7), 1468–1479. Dittmer, C. C., Fischer, D. D., Diedrich, K. K., & Thill, M. M. (2012). Diagnosis and treatment options of vulvar cancer: A review. Archives of Gynecology & Obstetrics, 285(1), 183–193. Doubilet, P. (2011). Diagnosis of abnormal uterine bleeding with imaging. Menopause (New York, NY), 18(4), 421–424. Faridi, R., Zahra, A., Khan, K., & Idrees, M. (2011). Oncogenic potential of human papillomavirus (HPV) and its relation with cervical cancer. Virology Journal, 8(1), 269–276. Forouzanfar, M., Foreman, K., Delossantos, A., Lozano, R., Lopez, A., Murray, C., & Naghavi, M. (2011). Breast and cervical cancer in 187 countries between 1980 and 2010: a systematic analysis. Lancet, 378(9801), 1461–1484. Galaal, K., Bryant, A, Deane, K. H. O., Al-Khaduri, M., & Lopes, A. D. (2011). Interventions for reducing anxiety in women undergoing colposcopy. Cochrane Database of Systematic Reviews, 2011(12). doi:10.1002/14651858.CD006013.pub3 Ghebre, R. G., Posthuma, R., Vogel, R., Geller, M. A., & Carson, L. F. (2011). Effect of age and comorbidity on the treatment and survival of older patients with vulvar cancer. Gynecologic Oncology, 121(3), 595–599. Hartge, P. (2010). Designing early detection programs for ovarian cancer. Journal of the National Cancer Institute, 102(1), 3–4. Healthwise. (2010). The Bethesda System. Retrieved from http://health. msn.com/health-topics/articlepage.aspx?cp-documentid=100069016 Helm, C. W. (2011). Ovarian cysts. eMedicine. Retrieved from http:// emedicine.medscape.com/article/255865-overview Holtan, S., & Creedon, D. (2011). Mother knows best: Lessons from feto-maternal tolerance applied to cancer immunity. Frontiers in Bioscience (Scholar Edition), 3, 1533–1540. International Federation of Gynecology & Obstetrics. (2011). Endometrial carcinoma staging. Retrieved from http://www.figo.org/search/ node/endometrial+cancer+staging Khalil, I., Brewer, M., Neyarapally, T., & Runowicz, C. (2010). The potential of biologic network models in understanding the etiopathogenesis of ovarian cancer. Gynecologic Oncology, 116(2), 282–285. Klossner, N. J., & Hatfield, N. T. (2009). Introductory maternity and pediatric nursing (2nd ed.). Philadelphia, PA: Lippincott Williams & Wilkins. Kurian, A. (2010). BRCA1 and BRCA2 mutations across race and ethnicity: Distribution and clinical implications. Current Opinion in Obstetrics & Gynecology, 22(1), 72–78. Kwon, Y.-S., Mok, J.-E., Lim, K.-T., Lee, I.-H., Kim, T.-J., Lee, K.-H., & Shim J.-U. (2010). Ovarian cancer during pregnancy: Clinical and pregnancy outcome. Journal of Korean Medical Science, 25(2), 230–234.



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le Grange, F., & McCormack, M. (2011). Cervical cancer during ­pregnancy—An approach to diagnosis and management. Current Women’s Health Reviews, 7(1), 82–86. Mayo Clinic (2010). Cancer prevention: 7 steps to reduce your risk. Retrieved from http://www.mayoclinic.com/health/cancer-prevention/ CA00024 Moore, R., MacLaughlan, S., & Bast, R. (2010). Current state of biomarker development for clinical application in epithelial ovarian cancer. Gynecologic Oncology, 116(2), 240–245. National Cancer Institute [NCI]. (2011a). Cancer surveillance, epidemiology & end results. Retrieved from http://seer.cancer.gov/ data/2011update.html National Cancer Institute [NCI]. (2011b). Cervical cancer. Retrieved from http://www.cancer.gov/cancertopics/types/cervical National Cancer Institute [NCI]. (2011c). Cervical cancer prevention. Retrieved from http://www.cancer.gov/cancertopics/pdq/prevention/ cervical/Patient/page3#Keypoint11 National Cancer Institute [NCI]. (2011d). Endometrial cancer. Retrieved from http://www.cancer.gov/cancertopics/types/endometrial National Cancer Institute [NCI]. (2011e). Lifetime risk of developing or dying of cancer. Retrieved from http://seer.cancer.gov/statistics/ types/lifetimerisk.html National Cancer Institute [NCI]. (2011f). Vaginal cancer. Retrieved from http://www.cancer.gov/cancertopics/types/vaginal National Cancer Institute [NCI]. (2011g). Vulvar cancer. Retrieved from http://www.cancer.gov/cancertopics/types/vulvar National Institutes of Health. (2011). Cervical cancer: Prevention. National Cancer Institute. Retrieved from http://www.nci.nih.gov/cancertopics/pdq/prevention/cervical/ HealthProfessional/page2 Pavlidis, N. (2011). Cancer and pregnancy: what should we know about the management with systemic treatment of pregnant women with cancer?. European Journal Of Cancer, 47 Suppl 3 S348–S352. Petracci, E., Decarli, A., Schairer, C., Pfeiffer, R., Pee, D., Masala, G., & ... Gail, M. (2011). Risk factor modification and projections of absolute breast cancer risk. Journal Of The National Cancer Institute, 103(13), 1037–1048. Pocobelli, G., Doherty, J., Voigt, L., Beresford, S., Hill, D., Chen, C., . . . Weiss, N. (2011). Pregnancy history and risk of endometrial cancer. Epidemiology (Cambridge, MA), 22(5), 638–645. Rossing, M. A., Wicklund, K. G., Cushing-Haugen, K. L., & Weiss, N. S. (2010). Predictive value of symptoms for early detection of ovarian cancer. Journal of the National Cancer Institute. Retrieved from http://www.ncbi.nlm.nih.gov/sites/entrez?orig_db=PubMed&db=pu bmed&cmd=Search&TransSchema=title&term=20110551 Rowney, J. (2011). Skin cancer prevention. Community Practitioner: The Journal Of The Community Practitioners’ & Health Visitors’ ­Association, 84(3), 12.

Rowlands, I., Nagle, C., Spurdle, A., & Webb, P. (2011). Gynecological conditions and the risk of endometrial cancer. Gynecologic Oncology, 123(3), 537–541. Saca-Hazboun, H., & Glennon, C. (2011). Cultural influences on health care in Palestine. Clinical Journal of Oncology Nursing, 15(3), 281–286. Schuiling, K. D., & Likis, F. E. (2013). Women’s gynecologic health (2nd ed.). Sudbury, MA: Jones & Bartlett. Smith, A., Rocconi, R.P., & Finan, M.A. (2012) Signs of aging or the vague symptoms of ovarian cancer? Oncology Nursing Forum. 39(2), 150–156. Taylor, S.E., & Green, J.A. (2012) Towards individualization of treatment for endometrial cancer. British Journal of Cancer. 106, 1581–1582. Tixier, H., Fraisse, J., Chauffert, B., Mayer, F., Causeret, S., Loustalot, C., . . . Cuisenier, J. (2010). Evaluation of pelvic posterior exenteration in the management of advanced-stage ovarian cancer. Archives of Gynecology and Obstetrics, 281(3), 505–510. U.S. Department of Health and Human Services. (2010). Healthy People 2020. Retrieved from http://www.healthypeople.gov/2020/ topicsobjectives2020 U.S. Preventive Services Task Force [USPSTF]. (2011). Screening for ovarian cancer. U.S. Preventive Services Task Force summary of recommendations. Retrieved from http://www.ahrq.gov/clinic/pocketgd1011/gcp10s2.htm van de Vijver, A., Poppe, W., Verguts, J., & Arbyn, M. (2010). Pregnancy outcome after cervical conization: A retrospective cohort study in the Leuven University Hospital. International Journal of Obstetrics & Gynecology, 117(3), 268–273. Vandenput, I., Trovik, J., Vergote, I., Moerman, P., Leunen, K., Berteloot, P.,​ . . . Amant, F. (2011). The role of adjuvant chemotherapy in surgical stages I–II serous and clear cell carcinomas and carcinosarcoma of the endometrium: A collaborative study. International Journal of Gynecological Cancer, 21(2), 332–336. Voulgaris, E. E., Pentheroudakis, G. G., & Pavlidis, N. N. (2011). Cancer and pregnancy: A comprehensive review. Surgical Oncology, 20(4), e175–e185. Warman, J. (2010) Cervical cancer screening in young women: Saving lives with prevention and detection. Oncology Nursing Forum, 37(1), 33–38. World Health Organization. (2011). Cancer prevention. Retrieved from http://www.who.int/cancer/prevention/en Worthington, C., McLeish, K., & Fuller-Thompson, E. (2012) Adherence over time to cervical cancer screening guidelines: Insights from the Canadian National Population Health Survey. Journal of Women’s Health. 21(2), 199–208. Zhang, J., Meng, Q., Chang, W., & Wan, C. (2010) Clinical assessment of the efficacy of anti-cancer treatment: Current status and perspectives. Chinese Journal of Cancer. 29(2), 234–238.

CHAPTER W O R K S H E E T MULTIPLE-CHOICE QUESTIONS

CRITICAL THINKING EXERCISES

1. When describing ovarian cancer to a local women’s group, the nurse states that ovarian cancer often is not diagnosed early because: a. The disease progresses very slowly. b. The early stages produce very vague symptoms. c. The disease usually is diagnosed only at autopsy. d. Clients do not follow up on acute pelvic pain.

1. A 27-year-old sexually active Caucasian woman visits the Health Department family planning clinic and requests information about the various available methods of contraception. In taking her history, the nurse learns that she started having sex at age 15 and has had multiple sex partners since then. She smokes two packs of cigarettes daily. Because she has been unemployed for a few months, her health insurance policy has lapsed. She has never previously obtained any gynecologic care. a. Based on her history, which risk factors for cervical cancer are present? b. What recommendations would you make for her and why? c. What are this client’s educational needs concerning health maintenance?

2. A postmenopausal woman reports that she has started spotting again. Which of the following would the nurse do? a. Instruct the client to keep a menstrual diary for the next few months. b. Tell her not to worry, since this a common but not serious event. c. Have her start warm-water douches to promote healing. d. Anticipate that the doctor will assess her endometrium thickness. 3. Which of the following would the nurse identify as the priority psychosocial need for a women diagnosed with reproductive cancer? a. Research findings b. Hand-holding c. Cheerfulness d. Offering of hope 4. When teaching a group of women about screening and early detection of cervical cancer, the nurse would include which of the following as most effective? a. Fecal occult blood test b. CA-125 blood test c. Pap smear d. Sigmoidoscopy 5. After teaching a group of students about reproductive tract cancers, the nursing instructor determines that the teaching was successful when the students identify which of the following as the deadliest type of female reproductive cancer? a. Vulvar b. Ovarian c. Endometrial d. Cervical

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2. A 60-year-old nulliparous woman presents to the gynecologic oncology clinic after her health care provider palpated an adnexal mass on her right ovary. In taking her history, the nurse learns that she has experienced mild abdominal bloating and weight loss for the past several months but felt fine otherwise. She was diagnosed with breast cancer 15  years ago and was treated with a lumpectomy and radiation. She has occasionally used talcum powder in her perineal area over the past 20 years. A transvaginal ultrasound reveals a complex mass in the right adnexa. She undergoes a total abdominal hysterectomy and bilateral salpingo-oophorectomy and lymph node biopsy. Pathology confirms a diagnosis of stage III ovarian cancer with abdominal metastasis and positive lymph nodes. a. Is this client’s profile typical for a woman with this diagnosis? b. What in her history might have increased her risk for ovarian cancer? c. What can the nurse do to increase awareness of this cancer for all women?

CHAPTER W O R K S H E E T STUDY ACTIVITIES 1. During your surgical clinical rotation, interview a female client undergoing surgery for cancer of her reproductive organs. Ask her to recall the symptoms that brought her to the health care provider. Ask her what thoughts, feelings, and emotions went through her mind before and after her diagnosis. Finally, ask her how this experience will change her life in the future. 2. Visit an oncology and radiology treatment center to find out about the various treatment modalities available for reproductive cancers. Contrast the various treatment methods and report your findings to your class.

3. Visit one of the web sites listed in the exstensive list of websites provided on to explore a topic of interest concerning reproductive cancers. How correct and current is the content? What is its level? Share your assessment with your classmates. 4. Taking oral contraceptives provides protection against ___________________ cancer. 5. Two genes, BRCA1 and BRCA2, are linked with hereditary ________________ and ________________ cancers.

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9 KEY TERMS acquaintance rape battered women syndrome cycle of violence date rape female genital cutting (FGC) human trafficking incest intimate partner violence (IPV) post-traumatic stress disorder (PTSD) rape sexual abuse statutory rape

Violence and Abuse Learning Objectives After completion of the chapter, you will be able to: 1. Define the key terms used in this chapter. 2. Examine the incidence of violence in women. 3. Characterize the cycle of violence and appropriate interventions. 4. Evaluate the various myths and facts about violence. 5. Analyze the dynamics of rape and sexual abuse. 6. Select the resources available to women experiencing abuse. 7. Outline the role of the nurse who cares for abused women.

Dorothy came to the prenatal clinic with a complaint of recurring headaches. She had been in twice this week already, but insisted she be seen today and started to cry. When the nurse called her into the examination room, Dorothy’s cell phone rang. She hurried to answer it and told the person on the other end that she was at the store. When the nurse asked if she was afraid at home, Dorothy answered “at times.” What cues did the nurse pick up on to ask that question? How frequent is this problem in women?

WOW

Words of Wisdom

After being traumatized, women can decide to stay in the shallow end of the pool or they can find support and swim in the ocean.



Gender-based violence is a major public health and human rights problem and one that often goes unrecognized and unreported. It is a common source of physical, psychological, and emotional morbidity. It occurs in all countries, irrespective of social, economic, religious, or cultural group. Pregnancy is a time of unique vulnerability to intimate partner violence (IPV) victimization because of changes in women’s physical, social, emotional, and economic needs during pregnancy. Although the true prevalence of violence during pregnancy is unclear, research suggests it is substantial and often continues into the postpartum period (Brownridge et al., 2011). Female-perpetrated violence against male partners receives little attention. Estimates suggest that 21.6% of men are victims of physical aggression by female partners, (Desmarais, Reeves, Nicholls, Telford, & Fiebert 2012). Although women can be violent in relationships with men, and also in same-sex partnerships, the overwhelming burden of partner violence is borne by women at the hands of men. Nearly 3  in 10 women and 1 in 10 men in the United States have experienced rape, physical violence, and/or stalking by a partner with IPV-related impact (Centers for Disease Control and Prevention [CDC], 2012). For all the strides American women have made in the past 100  years, obliterating violence against themselves is not one of them. Violence against women is a growing problem. In many countries it is still accepted as part of normal behavior. According to the Federal Bureau of Investigation (FBI) (2011), up to half of all women in the United States will experience some form of physical violence during their lifetime. In North America 40% to 60% of murders of women are committed by intimate partners (FBI, 2011). Recently, the FBI has broadened its definition of rape. The new definition, as it appears on the FBI web site, is “Penetration, no matter how slight, of the vagina or anus with any body part or object, or oral penetration by a sex organ of another person, without the consent of the victim.” This broader definition will dramatically impact the way rape is tracked and reported nationwide (FBI 2011). Federal funding for the problem is trickling down to local programs, but it is not reaching victims fast enough. For example, the United States has three times more shelters for animals than for battered women (Barner & ­Carney, 2011). In many cases, a victim escapes her abuser only to be turned away from a local shelter b ­ ecause it is full. The number of abused women is staggering: one woman is being battered every 12 seconds in the United States (CDC, 2011b). Nurses play a major role in assessing women who have suffered some type of violence. Often, after a woman is victimized, she will complain about physical ailments that will give her the opportunity to visit a health care setting. A visit to a health care agency is an ideal time for women to be assessed for violence. Because nurses

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are viewed as trustworthy and sensitive about very personal subjects, women often feel comfortable confiding in them and discussing these issues with them. As a professional nurse, the act of screening women seen in every health care setting is often the first step for a victim to start thinking about a better future. Remember, your words carry weight with your client who looks to you for help, support, and encouragement.



Take Note!

Nurses will come in contact with violence and sexual abuse no matter what health care setting they work in. Nurses must be ready to ask the right questions and to act on the answers, because such action could be lifesaving. This chapter addresses two types of gender-based violence: intimate partner violence and sexual abuse. Both types of violence against women have devastating and costly consequences for all of society.

INTIMATE PARTNER VIOLENCE Intimate partner violence (IPV) is actual or threatened physical or sexual violence or psychological/­emotional abuse. Research suggests that physical violence in intimate relationships is often accompanied by psychological abuse and in one third to over one half of cases by sexual abuse (CDC, 2011b). Intimate partners include individuals who are currently in dating, cohabitating, or marital relationships, or those who have been in such relationships in the past. Some of the common terms used to describe IPV are domestic abuse, spouse abuse, domestic violence, gender-based violence, battering, and rape. Intimate partner violence affects a distressingly high percentage of the population and has physical, psychological, social, and economic consequences (Fig. 9.1).

FIGURE 9.1 Intimate partner violence has significant physical, psychological, social, and economic consequences. An important role of the health care provider is to identify abusive or potentially abusive situations as soon as possible and provide support for the victim.

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Because a nurse may be the first health care professional to assess and identify the signs of intimate partner violence, nurses can have a profound impact on a woman’s decision to seek help. Thus, it is important for nurses to be able to identify abuse and aid the victim. Intimate partner violence can leave significant psychological scars, and a well-trained nurse can have a positive impact on the victim’s mental and emotional health.

Incidence Overall, lifetime, and 1-year estimates for sexual violence, stalking, and intimate partner violence are alarmingly high for adult Americans, with IPV alone affecting more than 12 million people each year. Women are disproportionately impacted. The estimated cost of violence in the United States exceeds $70 billion each year. Each year, IPV results in an estimated 2,500  deaths and 3  ­million injuries among women (CDC, 2011b). Women are at risk for violence at nearly every stage of their lives. Old, young, beautiful, unattractive, married, single—no woman is completely safe from the risk of intimate partner violence. Current or former husbands or lovers kill over half of the murdered women in the United States. Intimate partner violence against women causes more serious injuries and deaths than automobile accidents, rapes, and muggings combined. The medical cost of IPV approaches $13 billion each year to pay for medical and surgical care, counseling, child care, incarceration, attorney fees, and loss of work productivity (Kruse, Sørensen, Brønnum-Hansen, & Helweg-Larsen, 2011). Intimate partner violence is pervasive and crosses all boundaries of sexual orientation, race, and class. Scholars contend that the intimidation of another person through abusive acts and words is not a gender issue. Violence within these relationships may go unreported for fear of harassment or ridicule. The medical community’s efforts to address intimate partner violence have often neglected members of the lesbian, gay, bisexual, and transgender (LGBT) population. Heterosexual women are primarily targeted for IPV screening and intervention despite the similar prevalence of IPV in LGBT individuals and its detrimental health effects (Ard & Makadon, 2011). Perhaps because of the multiple barriers that confront LGBT abuse victims and the invisibility of the problem in the context of IPV services, the role of the nurse as their advocate is all the more critical.

Background Until the mid-1970s, our society tended to legitimize a man’s power and control over a woman. The U.S. legal and judicial systems considered intervention into family disputes wrong and a violation of the family’s right to privacy. Intimate partner violence was often tolerated

H E A LT H Y P E O P LE 2020 Objective

Nursing Significance

1. (Developmental) Reduce violence by current or former intimate partners, including: • Reduce physical violence • Reduce sexual violence • Reduce psychological abuse • Reduce stalking 2. (Developmental) R ­ educe sexual v­ iolence, including: • Reduce rape or a­ ttempted rape • Reduce abusive sexual contact other than rape or attempted rape • Reduce noncontact sexual abuse 3. (Developmental) Improve the health, safety, and well-being of lesbian, gay, bisexual, and transgender (LGBT) individuals.

• Will increase women’s quality and years of healthy life • Eliminate health disparities for survivors of violence • Goal is to have 90% compliance in screening for intimate partner violence by health professionals. • Meeting these objectives will reflect the importance of early detection, intervention, and evaluation.

• Eliminating LGBT health disparities and enhancing efforts to improve LGBT health are necessary to ensure that LGBT individuals can lead long, healthy lives.

Healthy People objectives based on data from http://www .healthypeople.gov.

and even socially acceptable. Fortunately, attitudes and laws have changed to protect women and punish abusers. In Healthy People 2020, three developmental objectives address violence against heterosexual women and the LGBT population (U.S. Department of Health and Human Services [USDHHS], 2010b).

Characteristics of Intimate Partner Violence Although more research is needed in this area, studies have found certain risk factors for intimate partner violence in men. These risk factors can be divided into four different categories: individual factors, relationship factors, community factors, and societal factors. Specific risk factors within each category are listed in Box 9.1



C h a p t e r 0 9  Violence and Abuse   281 BOX 9.1

RISK FACTORS FOR INTIMATE PARTNER VIOLENCE IN MEN Individual Factors

Relationship Factors

Community Factors

Societal Factors

Young age

Martial conflict

Weak sanctions against IPV

Traditional gender norms

Heavy drinking

Economic stress

Poverty

Social norms supportive of violence

Personality disorders

Dysfunctional family

Low social capital

Depression

Marital instability

Low academic achievement

Male dominance in family

Witnessing violence as a child

Cohabitation

Low income

Having outside sexual partners

Experiencing violence as a child Adapted from Abramsky, T., Watts, C. H., Garcia-Moreno, C., Devries, K., Kiss, L., Ellsberg, M., . . . Heise, L. (2011). What factors are associated with recent intimate partner violence? Findings from the WHO multi-country study on women’s health and domestic violence. BMC Public Health, 11(1), 109–125; Pinto, S., & Schub, T. (2010). Intimate partner violence, physical abuse. Retrieved from CINAHL Plus with Full Text database; and World Health Organization [WHO]. (2011). Violence against women. Retrieved from http://www.who.int/mediacentre/ factsheets/s239/en/index.html.

Generation-to-Generation Continuum of Violence Violence is a learned behavior that, without intervention, is self-perpetuating. It is a cyclical health problem. The long-term effects of violence on victims and children can be profound. Children who witness one parent abuse another are more likely to become delinquents or batterers themselves because they see abuse as an integral part of a close relationship. Thus, an abusive relationship between father and mother can perpetuate future abusive relationships. Research has found that children who witness intimate partner violence are at risk for developing psychiatric disorders, developmental problems, school failure, violence against others, and low self-­ esteem (Lamers-Winkelman, Willemen, & Visser 2012). Childhood maltreatment is a major health problem that is associated with a wide range of physical conditions and leads to high rates of psychiatric morbidity and social problems in adulthood. Women who were physically or sexually abused as children have an increased risk of victimization and experience adverse mental health conditions such as depression, anxiety, and low self-esteem as adults (Caldwell, Swan & Woodbrown 2012). In 50% to 75% of the cases when a parent is abused, the children are abused as well (Howard 2012). Exposure to violence has a negative impact on children’s physical, emotional, and cognitive well-being. The cycle continues into another generation through learned responses and violent acting out. Although there are always exceptions, most children deprived of their basic physical, psychological, and

spiritual needs do not develop healthy personalities. They grow up with feelings of fear, inadequacy, anxiety, anger, hostility, guilt, and rage. They often lack coping skills, blame others, demonstrate poor impulse control, and generally struggle with authority (Riggs, 2010). Unless this cycle is broken, more than half become abusers themselves (CDC, 2011b).

The Cycle of Violence In an abusive relationship, the cycle of violence comprises three distinct phases: the tension-building phase, the acute battering phase, and the honeymoon phase (Burnett & Adler, 2011). The cyclical behavior begins with a time of tension-building arguments, progresses to violence, and settles into a making-up or calm period. This cycle of violence increases in frequency and severity as it is repeated over and over again. The cycle can cover a long or short period of time. The honeymoon phase gradually shortens and eventually disappears altogether. Abuse in relationships typically becomes accelerated and thus more dangerous over time. The abuser no longer feels the need to apologize and indulge in a honeymoon phase as the woman becomes increasingly disempowered in the relationship. PHASE 1: TENSION BUILDING During the first—and usually the longest—phase of the cycle, tension escalates between the couple. Excessive drinking, jealousy, or other factors might lead to name-calling, hostility, and friction. The woman might sense that her partner is reacting to her more negatively, that he is on edge

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and reacts heatedly to any trivial frustration. A woman often will accept her partner’s building anger as legitimately directed toward her. She internalizes what she perceives as her responsibility to keep the situation from exploding. In her mind, if she does her job well, he remains calm. But if she fails, the resulting violence is her fault. PHASE 2: ACUTE BATTERING The second phase of the cycle is the explosion of violence. The batterer loses control both physically and emotionally. This is when the victim may be assaulted or murdered. After a battering episode, most victims consider themselves lucky that the abuse was not worse, no matter how severe their injuries. They often deny the seriousness of their injuries and refuse to seek medical treatment. PHASE 3: HONEYMOON The third phase of the cycle is a period of calm, loving, contrite behavior on the part of the batterer. He may be genuinely sorry for the pain he caused his partner. He attempts to make up for his brutal behavior and believes he can control himself and never hurt the woman he loves. The victim wants to believe that her partner really can change. She feels responsible, at least in part, for causing the incident, and she feels responsible for her partner’s well-being (Box 9.2).

Types of Abuse Abusers may use whatever it takes to control a situation— from emotional abuse and humiliation to physical assault. Victims often tolerate emotional, physical, financial, and

BOX 9.2

sexual abuse. Many remain in abusive relationships because they believe they deserve the abuse.

Emotional Abuse Emotional abuse includes: • Promising, swearing, or threatening to hit the victim • Forcing the victim to perform degrading or humiliating acts • Threatening to harm children, pets, or close friends • Humiliating the woman by name-calling and insults • Threatening to leave her and the children • Destroying valued possessions • Controlling the victim’s every move

Physical Abuse Physical abuse includes: • Hitting or grabbing the victim so hard that it leaves marks • Throwing things at the victim • Slapping, spitting at, biting, burning, pushing, choking, or shoving the victim • Kicking or punching the victim, or slamming her against things • Attacking the victim with a knife, gun, rope, or electrical cord • Controlling access to health care for injury

Financial Abuse Financial abuse includes: • Preventing the woman from getting a job • Sabotaging a current job • Controlling how all money is spent • Failing to contribute financially

CYCLE OF VIOLENCE • Phase 1—Tension building: Verbal or minor battery occurs. Almost any subject, such as housekeeping or money, may trigger the buildup of tension. The victim attempts to calm the abuser. • Phase 2—Acute battering: Characterized by uncontrollable discharge of tension. Violence is rarely triggered by the victim’s behavior: she is battered no matter what her response. • Phase 3—Reconciliation (honeymoon)/calm phase: The batterer becomes loving, kind, and apologetic and expresses guilt. Then the abuser works on making the victim feel responsible. Adapted from Aggeles, T. B. (2012). Domestic violence advocacy, Florida, update. Retrieved from http://ce.nurse.com/60133/Course­ Page; Association of Women’s Health, Obstetric and Neonatal Nurses. (2010). Violence against women: Identification, screening and management of intimate partner violence. Retrieved from http://www. awhonn.org; and Riggs, S. (2010). Childhood emotional abuse and the attachment system across the life cycle: What theory and research tell us. Journal of Aggression, Maltreatment & Trauma, 19(1), 5–51.

Sexual Abuse Sexual abuse includes: • Forcing the woman to have vaginal, oral, or anal intercourse against her will • Biting the victim’s breasts or genitals • Shoving objects into the victim’s vagina • Forcing the woman to do something sexual that she finds degrading or humiliating • Forcing the victim to perform sexual acts on other people or animals

Myths and Facts About Intimate Partner Violence Table 9.1 lists many of the myths about intimate partner violence. Health care providers should take steps to dispel these myths.



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TABLE 9.1

COMMON MYTHS AND FACTS ABOUT VIOLENCE

Myths

Facts

Battering of women occurs only in lower s­ ocioeconomic classes.

Violence occurs in all socioeconomic classes.

Substance abuse causes the violence.

Violence is a learned behavior and can be changed. The presence of drugs and alcohol can make a bad problem worse.

Violence occurs to only a small percentage of women.

One in four women will be victims of violence.

Women can easily choose to leave an abusive relationship.

Women stay in the abusive relationship because they feel they have no options.

Only men with mental health problems commit violence against women.

Abusers often seem normal and do not appear to suffer from personality disorders or other forms of mental illness.

Pregnant women are protected from abuse by their partners.

One in five women is physically abused during pregnancy. The effects of violence on infant outcomes can include preterm delivery, fetal distress, low birth weight, and child abuse.

Women provoke their partners to abuse them.

Women may be willing to blame themselves for someone else’s bad behavior, but nobody deserves to be beaten.

Violent tendencies have gone on for generations and are accepted.

The police, justice system, and society are beginning to make domestic violence socially unacceptable.

IPV is only a heterosexual issue.

There is as much IPV in the LGBT population as in heterosexual relationships with the added psychological abuse of “outing” (when one partner threatens to disclose the others sexual preference in an effort to maintain power and control).

Adapted from Aggeles, T. B. (2012). Domestic violence advocacy, Florida, update. Retrieved from http://ce.nurse.com/60133/CoursePage; Association of Women’s Health, Obstetric and Neonatal Nurses. (2010). Violence against women: Identification, screening and management of intimate partner violence. Retrieved from http://www.awhonn.org; and Jankowski, P. J., Johnson, A. J., Holtz Damron, J. E., & Smischney, T. (2011). Religiosity, intolerant attitudes, and domestic violence myth acceptance. International Journal for the Psychology of Religion, 21(3), 163–182.

Abuse Profiles Victims Ironically, victims rarely describe themselves as abused. In battered woman syndrome, the woman has experienced deliberate and repeated physical or sexual assault by an intimate partner. She is terrified and feels trapped, helpless, and alone. She reacts to any expression of anger or threat by avoidance and withdrawal behavior. Some women believe that the abuse is caused by a personality flaw or inadequacy in themselves (e.g., inability to keep the man happy). These feelings of failure are reinforced and exploited by their partners. After being told repeatedly that they are “bad,” some women begin to believe it. Many victims were abused as children and may have poor self-esteem, depression, insomnia, low education achievement, or a history of suicide

attempts, injury, or drug and alcohol abuse (Cronholm, Fogerty, Ambuel, & Harrison, 2011).

Abusers A1busers come from all walks of life and often feel insecure, powerless, and helpless, feelings that are not in line with the macho image they would like to project. The abuser expresses his feelings of inadequacy through violence or aggression toward others (Burnett & Adler, 2011). Violence typically occurs at home and is usually directed toward the man’s intimate partner or the children who live there. Abusers refuse to share power and choose violence to control their victims. They often exhibit childlike aggression or antisocial behaviors. They may fail to accept responsibility or blame others for their own problems. They might also have a history

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of substance abuse problems, trouble with the justice system, few close relationships, being sensitive to criticism, having a tendency to hold grudges, involved in power struggles, emotionally disregulated, lacking in insight, prone to feeling misunderstood, mistreated, or victimized, mental illness, arrests, troubled relationships, obsessive jealousy, controlling behaviors, generally violent behavior, erratic employment history, and financial problems (Fowler & Westen, 2011).

Violence Against Pregnant Women Many think of pregnancy as a time of celebration and planning for the unborn child’s future, but in a troubled relationship it can be a time of escalating violence. The strongest predictor of abuse during pregnancy is prior abuse (Steen & Keeling 2012). For women who have been abused before, beatings and violence during pregnancy are “business as usual” for them. Women are at a higher risk for violence during pregnancy. Recent research findings indicate that having children does not protect women from IPV. On the contrary, the IPV appears to last longer if women have children, and this also seems to be the case even after the partnership has come to an end (Vatnar & Bjørkly, 2010). Pregnant women are vulnerable during this time, and abusers can take advantage of it. An estimated 350,000 pregnant women are abused by their partners each year (CDC, 2011a). Abuse during pregnancy poses special risks and dynamics. Various factors may lead to battering during pregnancy, including: • Inability of the couple to cope with the stressors of pregnancy • Young age at time of pregnancy • Having less than a high school education for both partners • Unemployment for either or both in partnership • Violence in the family of origin • Cohabitation and single marital status • Sexual proprietariness on the part of the male partner • Heavy drinking by partner • Resentment toward the interference of the growing fetus and change in the woman’s shape • Doubts about paternity or the expectant mother’s fidelity during pregnancy • Perception that the baby will be a competitor • Outside attention the pregnancy brings to the woman • Unwanted pregnancy • The woman’s new interest in herself and her unborn baby • Insecurity and jealousy about the pregnancy and the responsibilities it brings • Financial burden related to expense of pregnancy and loss of income • Stress of role transition from adult man to becoming the father of a child

• Physical and emotional changes of pregnancy that make the woman vulnerable • Previous isolation from family and friends that limit the couple’s support system Abuse during pregnancy threatens the well-being of the mother and fetus. Physical violence may involve injuries to the head, face, neck, thorax, breasts, and abdomen. The mental health consequences are also significant. Several studies have confirmed the relationship between abuse and poor mental health, especially depression and post-traumatic stress disorder (PTSD); poor quality of life; increased distress, fearfulness, anxiousness, and stressfulness; and increased use of tobacco, alcohol, and/or illicit drugs (Brownridge et al., 2011). For the pregnant woman, many of these conditions most often manifest during the postpartum period.



Take Note! Frequently the fear of harm to her unborn child will motivate a woman to escape an abusive relationship.

Women assaulted during pregnancy are at risk for: • Injuries to themselves and the fetus • Depression • Panic disorder • Fetal and maternal deaths • Chronic anxiety • Miscarriage • Stillbirth • Poor nutrition • Insomnia • Placental abruption • Uterine rupture • Excessive weight gain or loss • Smoking and substance abuse • Delayed or no prenatal care • Preterm labor • Chorioamnionitis • Vaginitis • Sexually transmitted infections • Urinary tract infections • Premature and low-birth-weight infants (ACOG 2012). Signs of abuse can emerge during pregnancy and may include poor attendance at prenatal visits, unrealistic fears, weight fluctuations, difficulty with pelvic examinations, and noncompliance with treatment. See EvidenceBased Practice 9.1 for an intervention utilized for pregnant women experiencing IPV. Uncovering abuse in pregnant women requires a consistent and direct approach to every client by the nurse. Multiple assessments may enhance reporting by enabling the nurse to establish trust and rapport with the woman and identify changes in her behavior. Once abuse



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EVIDENCE-BASED PRACTICE 9.1

AN INTEGRATED INTERVENTION TO REDUCE INTIMATE PARTNER VIOLENCE IN PREGNANCY: A RANDOMIZED CONTROLLED TRIAL

STUDY This study was designed to estimate the efficacy of a psychobehavioral intervention in reducing intimate partner violence recurrence during pregnancy and postpartum and in improving birth outcomes in African American women. A randomized controlled trial was conducted for which 1,044 women were recruited. Women were randomly assigned to receive either intervention (n = 521) or usual care (n = 523). Individually tailored counseling sessions were adapted from evidence-based interventions for intimate partner violence and other risks. Logistic regression was used to model intimate partner violence victimization recurrence and to predict minor, severe, physical, and sexual intimate partner violence

Findings Women randomly assigned to the intervention group were less likely to have recurrent episodes of intimate partner violence victimization. Women with minor intimate partner violence were significantly less likely to

experience further episodes during pregnancy and postpartum. Women with severe intimate partner violence showed significantly reduced episodes postpartum. Women who experienced physical intimate partner violence showed significant reduction at the first followup. Women in the intervention group had significantly fewer very preterm neonates (1.5% intervention group, 6.6% usual care group; P = 0.03) and an increased mean gestational age (38.2 ± 3.3 intervention group, 36.9 ± 5.9 usual care group; P = 0.016).

Nursing Implications Pregnant women at risk for abuse or in abusive relationships experience very stressful and complex lives. A relatively brief intervention (acknowledging her stress and listening) during pregnancy had discernible effects on intimate partner violence and pregnancy outcomes. Screening for intimate partner violence as well as other psychosocial and behavioral risks and incorporating similar interventions during the prenatal visits is highly recommended for all nurses to reduce violence against their clients.

Adapted from Kiely, M., El-Mohandes, A., El-Khorazaty, M., & Gantz, M. (2010). An integrated intervention to reduce intimate partner violence in pregnancy: A randomized controlled trial. Obstetrics and Gynecology, 115(2), 273–283.

is discovered in a pregnant woman, interventions should include safety assessment, emotional support, counseling, referral to community services, and ongoing prenatal care (Hawley & Hawley-Barker 2012).

Violence Against Older Women Intimate partner violence affects women of all ages, but often the literature focuses on women in the childbearing years, ignoring the problems of aging women experiencing abuse. All 50 states have laws requiring health care professionals to report elder or vulnerable person abuse. Estimates suggest that 500,000 to 2 million cases of elder abuse and neglect occur annually in the United States. Types of abuse experienced by the older woman may include physical abuse, neglect, emotional abuse, sexual abuse, and financial/­exploitation abuse (National Center on Elder Abuse, 2011). Although an injury may bring the older woman into the health care system, the physical and emotional sequelae of intimate partner violence may be more subtle and may include depression, insomnia, chronic pain, difficulty trusting others, low self-esteem, thoughts of suicide, substance abuse, anger issues, atypical chest pain, or other kinds of somatic symptoms. Research suggests that older women usually have endured long-term abuse, have developed unhealthy strategies to cope (substance abuse, keeping the family together at all cost, and ­physical/mental health consequences), and

shoulder blame from their adult children, yet have developed empowerment from within to be able to cope with the abuse ­(Tetterton & Farnesworth, 2011). Accurate detection and assessment of abuse in older women are essential duties of all nurses. As part of a thorough screening, nurses should determine what the client has done to attempt to resolve the abuse and the effectiveness of those strategies. Actions might have included passive acceptance, calling law enforcement, counseling, or other measures. In addition, taking time to establish rapport with older women builds a sense of trust, safety, and openness. Nurses must listen carefully and nonjudgmentally. Judging or criticizing the victim for her decisions might lead to the impression that she deserves the abuse or that she is to blame. Finally, nurses should attempt to stay current in their knowledge of referral resources to assist the older woman experiencing abuse. Some of these resources may be housing, transportation, medical services, employment, social services, and local support groups. A coordinated and comprehensive response to IPV is essential to reduce its sequelae.

Nursing Management of Intimate Partner Violence Victims Nurses encounter thousands of abuse victims each year in their practice settings, but many victims slip

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through the cracks. There are many things that nurses can do to help victims. Early recognition and intervention can significantly reduce the morbidity and mortality associated with intimate partner violence. To stop the cycle of violence, nurses need to know how to assess for and identify IPV and implement appropriate actions.

Assessment Routine screening for intimate partner violence is the first way to detect abuse. The nurse should build rapport by listening, showing an interest in the concerns of the woman, and creating an atmosphere of openness. Communicating support through a nonjudgmental attitude and telling the woman that no one deserves to be abused are first steps toward establishing trust and rapport. Rather than overlooking abused women as “chronic complainers,” astute nurses need to be vigilant for subtle clues of abuse. Learning how to assess for abuse is critical. Some basic assessment guidelines follow. SCREEN FOR ABUSE DURING EVERY HEALTH CARE VISIT Screening for violence takes only a few minutes and can have an enormously positive effect on the outcome for the abused woman. Any woman could be a victim; no single sign marks a woman as an abuse victim, but the following clues may be helpful: • Injuries: bruises, scars from blunt trauma, or weapon wounds on the face, head, and neck • Injury sequelae: headaches, hearing loss, joint pain, sinus infections, teeth marks, clumps of hair missing, dental trauma, pelvic pain, breast or genital injuries • Reported history of injury that is not consistent with the actual presenting problem • Mental health problems: depression, anxiety, substance abuse, eating disorders, suicidal ideation or suicide attempts, anger toward health provider, PTSD • Frequent tranquilizer or sedative use • Bruises to the upper arm, neck and face, abdomen, or breasts • Comments about emotional or physical abuse of “a friend” • Sexually transmitted infections or pelvic inflammatory disease • Frequent health care visits for chronic, stress-related disorders such as chest pain, headaches, back or pelvic pain, insomnia, injuries, anxiety, and gastrointestinal disturbances • Partner’s behavior at the health care visit: appears overly solicitous or overprotective, is unwilling to leave her alone with the health care provider, answers

questions for her, and attempts to control the situation (Aggeles, 2012; Garboden 2010; Soria, 2011)

Dorothy, who you met at the beginning of the chapter, has been frequenting the clinic with vague somatic complaints in recent weeks and admits she is sometimes afraid at home. She tells the nurse her partner doesn’t want her to work, even though he is only sporadically e­ mployed at low-paying jobs. What cues in her assessment might indicate abuse? What p ­ hysical signs might the nurse observe?

ISOLATE CLIENT IMMEDIATELY FROM FAMILY If abuse is detected, immediately isolate the woman to provide privacy and to prevent potential retaliation from the abuser. Asking about abuse in front of the perpetrator may trigger an abusive episode during the inter­view or at home. Ways to ensure the woman’s safety would be to take the victim to an area away from the abuser to ask questions. The assessment can take place anywhere—­ x-ray area, ultrasound room, elevator, ladies’ room, laboratory—that is private and away from the abuser. If abuse is detected, the nurse can do the following to enhance the nurse–client relationship: • Educate the woman about the connection between the violence and her symptoms. • Help the woman acknowledge what has happened to her and begin to deal with the situation. • Offer her referrals so she can get the help that will allow her to begin to heal.

Dorothy returns to the prenatal clinic a month later with anemia, inadequate weight gain, bruises on her face and neck, and second-­trimester bleeding. This time she is accompanied by her partner, who stays close to Dorothy. What questions should the nurse ask to assess the situation? Where is the ­appropriate location to ask these questions? What legal responsibilities does the nurse have concerning her ­observations?

ASK DIRECT OR INDIRECT QUESTIONS ABOUT ABUSE Violence against women is often unseen, unknown, and hidden in families. Questions to screen for abuse should be routine and handled just like any other question. Many nurses feel uncomfortable asking questions of this nature, but broaching the subject is important even if



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the answer comes later. Opening up the possibility for women to express themselves about their experience of abuse to a nurse sends out a clear message that violence should never be tolerated and not kept hidden; it also conveys the message that nurses care about women’s experiences and want to offer a best practice initial response. Just knowing that someone else knows about the abuse offers a victim some relief and may help her disclose it. Ask difficult questions in an empathetic and nonthreatening manner and remain nonjudgmental in all responses and interactions. Choose the type of question that makes you most comfortable. Direct and indirect questions produce the same results. “Does your partner hit you?” or “Have you ever been or are you now in an abusive relationship?” are direct questions. If that approach feels uncomfortable, try indirect questions: “We see many women with injuries or complaints like yours and often they are being abused. Is that what is happening to you?” or “Many women in our community experience abuse from their partners. Is anything like that happening in your life?” With either approach, nurses need to maintain a nonjudgmental acceptance of whatever answers the woman offers.

The SAVE Model is a screening protocol that nurses can use when assessing women for violence (Box 9.3). ASSESS IMMEDIATE SAFETY The Danger Assessment Tool (Box  9.4) helps women and health care providers assess the potential for homicidal behavior in an ongoing abusive relationship. It is based on research that showed several risk factors for abuse-related murders: • Increased frequency or severity of abuse • Presence of firearms • Sexual abuse • Substance abuse • Generally violent behavior outside of the home • Control issues (e.g., daily chores, friends, job, money) • Physical abuse during pregnancy • Suicide threats or attempts (victim or abuser) • Child abuse (Fairweather 2012). DOCUMENT AND REPORT YOUR FINDINGS If the interview reveals a history of abuse, accurate documentation is critical because this evidence may support the woman’s case in court. Documentation must include details about the frequency and severity of abuse; the

BOX 9.3

SAVE MODEL SCREEN all of your clients for violence by asking: • Within the last year, have you been physically hurt by someone? • Do you feel you are in control of your life? • Within the last year, has anyone forced you to engage in sexual activities? • Can you talk about your abuse with me now? • In general, how would you describe your present relationship? ASK direct questions in a nonjudgmental way: • Begin by normalizing the topic to the woman. • Make continuous eye contact with the woman. • Stay calm; avoid emotional reactions to what she tells you. • Never blame the woman, even if she blames herself. • Do not dismiss or minimize what she tells you, even if she does. • Wait for each answer patiently. Do not rush to the next question.

• Do not use formal, technical, or medical language. • Avoid using leading questions; be direct and to the point • Use a nonthreatening, accepting approach. VALIDATE the client by telling her: • You believe her story. • You do not blame her for what happened. • It is brave of her to tell you this. • Help is available for her. • Talking with you is a hopeful sign and a first big step. EVALUATE, educate, and refer this client by asking her: • What type of violence was it? • Is she now in any danger? • How is she feeling now? • Does she know that there are consequences to violence? • Is she aware of community resources available to help her?

Adapted from Association of Women’s Health, Obstetric and Neonatal Nurses. (2010). Violence against women: Identification, screening and management of intimate partner violence. Retrieved from http://www.awhonn.org; Rolling, E., & Brosi, M. (2010). A multi-leveled and integrated approach to assessment and intervention of intimate partner violence. Journal of Family Violence, 25(3), 229–236; and Todahl, J., & Walters, E. (2011). Universal screening for intimate partner violence: A systematic review. Journal of Marital & Family Therapy, 37(3), 355–369.

288   U N I T 2   Women’s Health Throughout the Life Span BOX 9.4

DANGER ASSESSMENT TOOL Several risk factors have been associated with increased risk of homicides (murders) of women and men in violent relationships. No one can predict what will happen in your case, but we would like you to be aware of the danger of homicide in situations of abuse and for you to see how many of the risk factors apply to your situation. (“He” refers to your husband, partner, ex-husband, ex-partner, or whoever is currently physically hurting you.) _____1. Has the physical violence increased in severity or frequency over the past year? _____2. Does he own a gun? _____3. Have you left him after living together during the past year? _____4. Is he unemployed? _____5. Has he ever used a weapon against you or threatened you with a lethal weapon? _____6. Does he threaten to kill you? _____7. Has he avoided being arrested for domestic violence? _____8. Do you have a child that is not his? _____9. Has he ever forced you to have sex when you did not wish to do so? ____10. Does he ever try to choke you? ____11. Does he use illegal drugs? By drugs, I mean “uppers” or amphetamines, “meth,” speed, angel dust, cocaine, “crack,” street drugs, or mixtures. ____12. Is he an alcoholic or problem drinker? ____13. Does he control most or all of your daily activities? For instance: does he tell you who you can be friends with, when you can see your family, how much money you can use, or when you can take the car? ____14. Is he violently and constantly jealous of you? (For instance, does he say “If I can’t have you, no one can.”) ____15. Have you ever been beaten by him while you were pregnant? ____16. Has he ever threatened or tried to commit suicide? ____17. Does he threaten to harm your children? ____18. Do you believe he is capable of killing you? ____19. Does he follow or spy on you, leave threatening notes or messages on answering machine, destroy your property, or call you when you don’t want him to? ____20. Have you ever threatened or tried to commit suicide? _____ Total “Yes” Answers Thank you. Please talk to your nurse, advocate, or counselor about what the Danger Assessment means in terms of your situation. Source: March of Dimes Danger Assessment questionnaire. (From Campbell, J. [1986]. Nursing assessment for risk of homicide with battered women. Advances in Nursing Science, 8(4), 36-51.)

location, extent, and outcome of injuries; and any treatments or interventions. When documenting, use direct quotes and be very specific: “He choked me.” Describe any visible injuries, and use a body map (outline of a woman’s body) to show where the injuries are. Obtain photos (with informed consent) or document her refusal if the woman declines photos. Pictures or diagrams can be worth a thousand words. Figure. 9.2 shows a sample documentation form for intimate partner violence. Laws in many states require health care providers to alert the police to any injuries that involve knives, firearms, or other deadly weapons or that present lifethreatening emergencies. If assessment reveals suspicion or actual indication of abuse, you can explain to the woman that you are required by law to report it.

Nursing Diagnosis When violence is suspected or validated, the nurse needs to formulate nursing diagnoses based on the completed assessment. Possible nursing diagnoses related to violence against women might include the following: • Deficient knowledge related to understanding the ­cycle of violence and availability of resources • Anxiety related to threat to self-concept, situational crisis of abuse • Situational low self-esteem related to negative family interactions • Powerlessness related to lifestyle of helplessness • Compromised individual and family coping related to abusive patterns

FIGURE 9.2 Intimate partner violence documentation form. (Reprinted from Home Healthcare Nurse, 17, Cassidy K, How to assess and intervene in domestic violence situations, 644– 72, Copyright 1999, with permission from Lippincott Williams & Wilkins.)

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Interventions If abuse is identified, nurses can undertake interventions that can increase the woman’s safety and improve her health. The goal of intervention is to enable the victim to gain control of her life. Provide sensitive, predictable care in an accepting setting. Offer step-­ by-step explanations of procedures. Provide educational materials about violence. Allow the victim to actively participate in her care and have control over all health care decisions. Pace your nursing interventions and allow the woman to take the lead. Communicate support through a nonjudgmental attitude. Carefully document all of your assessment findings and nursing interventions. Depending on when in the cycle of violence the nurse encounters the abused woman, goals may fall into three groups: • Primary prevention: aimed at breaking the abuse cycle through community educational initiatives by nurses, physicians, law enforcement, teachers, and clergy • Secondary prevention: focuses on dealing with victims and abusers in early stages, with the goal of preventing progression of abuse • Tertiary prevention: activities are geared toward helping severely abused women and children recover and become productive members of society and rehabilitating abusers to stop the cycle of violence. These activities are typically long term and expensive. A modified tool developed by Holtz and Furniss (1993)—the ABCDES—provides a framework for providing sensitive nursing interventions to abused women (Box 9.5). Specific nursing interventions for the abused woman include educating her about community services, providing emotional support, and offering a safety plan. EDUCATE THE WOMAN ABOUT COMMUNITY SERVICES A wide range of support services are available to meet the needs of victims of violence. Nurses should be prepared to help the woman take advantage of these opportunities. Services will vary by community but might include psychological counseling, legal advice, social services, crisis services, support groups, hotlines, housing, vocational training, and other community-based referrals. Give the woman information about shelters or ­services even if she initially rejects it. Give the woman the National Domestic Violence hotline number: (800) 799-7233. Since 1992, guidelines from the Joint Commission (2010) have required emergency departments to maintain lists of community referral agencies that deal with the victims of intimate partner violence.

BOX 9.5

THE ABCDES OF CARING FOR ABUSED WOMEN • A is reassuring the woman that she is not alone. The isolation by her abuser keeps her from knowing that others are in the same situation and that health care providers can help her. • B is expressing the belief that violence against women is not acceptable in any situation and that it is not her fault. Demonstrate by your actions and words that you believe her disclosure. • C is confidentiality, since the woman might believe that if the abuse is reported, the abuser will retaliate. Interview her in private, without her partner or family members being present. Assure her that you will not release her information without her permission. • D is documentation, which includes the following: 1. A clear quoted statement about the abuse in the woman’s own words 2. Accurate descriptions of injuries and the history of them 3. Information on the first, the worst, and the most recent abusive incident 4. Photos of the injuries (with the woman’s consent) • E is education about the cycle of violence and that it will escalate. 1. Educate about abuse and its health effects. 2.  Help her to understand that she is not alone. 3. Offer appropriate community support and referrals. 4. Display posters and brochures to foster awareness of this public health problem. • S is safety, the most important aspect of the intervention, to ensure that the woman has resources and a plan of action to carry out when she decides to leave. Adapted from Centers for Disease Control and Prevention [CDC]. (2012). Understanding intimate partner violence. National Center for Injury Prevention and Control. Retrieved from http://www.cdc.gov/ violenceprevention/pdf/ipv_factsheet-a.pdf; Cronholm, P., Fogarty, C., Ambuel, B., & Harrison, S. (2011). Intimate partner violence. American Family Physician, 83(10), 1165–1172; Holtz, H., & Furniss, K. K. (1993). The health care provider’s role in domestic violence. Trends in Health Care Law and Ethics, 15, 519–522; and Soria, S. (2011ç). Screening for intimate partner violence in the ambulatory care setting. AAACN Viewpoint, 33(3), 1–3.

PROVIDE EMOTIONAL SUPPORT Providing reassurance and support to a victim of abuse is key if the violence is to end. Nurses in all clinical settings can help victims to feel a sense of personal power and provide them with a safe and supportive environment. Appropriate action can help victims to express their thoughts and feelings in constructive ways, manage



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stress, and move on with their lives. Appropriate interventions are: • Strengthen the woman’s sense of control over her life by: • Teaching coping strategies to manage her stress • Assisting with activities of daily living to improve her lifestyle • Allowing her to make as many decisions as she can • Educating her about the symptoms of PTSD and their basis • Encourage the woman to establish realistic goals for herself by: • Teaching problem-solving skills • Encouraging social activities to connect with other people • Provide support and allow the woman to grieve for her losses by: • Listening to and clarifying her reactions to the traumatic event • Discussing shock, disbelief, anger, depression, and acceptance • Explain to the woman that: • Abuse is never OK. She didn’t ask for it and she doesn’t deserve it. • She is not alone and help is available. • Abuse is a crime and she is a victim. • Alcohol, drugs, money problems, depression, or jealousy does not cause violence, but these things can give the abuser an excuse for losing control and abusing her. • The actions of the abuser are not her fault. • Her history of abuse is believed. • Making a decision to leave an abusive relationship can be very hard and takes time. OFFER A SAFETY PLAN The choice to leave must rest with the victim. Nurses cannot choose a life for the victim; they can only offer choices. Leaving is a process, not an event. Victims may try to leave their abusers as many as seven or eight times before succeeding. Frequently, the final attempt to leave may result in the death of the victim. Women planning to leave an abusive relationship should have a safety plan, if possible (Teaching Guidelines 9.1).

Teaching Guidelines 9.1 SAFETY PLAN FOR LEAVING AN ABUSIVE RELATIONSHIP • When leaving an abusive relationship, take the f­ ollowing items: •  Driver’s license or photo ID •  Social Security number or green card/work permit •  Birth certificates for you and your children • Phone numbers for social services or women’s shelter



•  The deed or lease to your home or apartment •  Any court papers or orders •  A change of clothing for you and your children •  Pay stubs, checkbook, credit cards, and cash •  Health insurance cards •  If you need to leave a domestic violence situation

immediately, turn to authorities for assistance in gathering this material. • Develop a “game plan” for leaving and rehearse it. • Don’t use phone cards—they leave a trail to follow. Adapted from Burnett, L. B., & Adler, J. (2011). Domestic violence. eMedicine. Retrieved from http://emedicine.medscape.com/article/805546overview; March of Dimes. (2011). Abuse during pregnancy. Retrieved from http://www.marchofdimes.com/pregnancy/stayingsafe_abuse.html; and Trevillion, K. (2011). Domestic violence: Responding to the needs of patients. Nursing Standard, 25(26), 48–56.

SEXUAL VIOLENCE Sexual violence is both a public health problem and a human rights violation. Sexual violence includes intimate partner violence, human trafficking, incest, female genital cutting, forced prostitution, bondage, exploitation, neglect, infanticide, and sexual assault. It occurs worldwide and affects up to one third of women over a lifetime (Spohn & Tellis 2012). Once every 2 minutes, 30 times an hour, 1,871 times a day, girls and women in America are raped. One in six women and 1 in 33 men will be sexually assaulted during their lifetime (Rape, Abuse, and Incest National Network [RAINN], 2011c). Rape has been reported against females from age  6  months to 93 years, but it still remains one of the most underreported violent crimes in the United States. Estimates suggest that, somewhere in the United States, a woman is sexually assaulted every 2 minutes (RAINN, 2011c). The National Center for Prevention and Control of Sexual Assault estimates that two thirds of sexual assaults will not be reported (CDC, 2011b). Over the course of their lives, women may experience more than one type of violence. Sexual violence can have a variety of devastating short- and long-term effects. Women can experience psychological, physical, and cognitive symptoms that affect them daily. They can include chronic pelvic pain, headaches, backache, sexually transmitted infections, pregnancy, anxiety, denial, fear, withdrawal, sleep disturbances, guilt, nervousness, phobias, substance abuse, depression, sexual dysfunction, and PTSD, and many contemplate suicide (CDC, 2011b). A traumatic experience not only damages a woman’s sense of safety in the world, but it can also reduce her self-esteem and her ability to continue her education, to earn money and be productive, to have children and, if she has children, to nurture and protect them. Overall, sexually assaulted

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women exhibit lower functioning as adults afterward (Cleverly & Boyle, 2010).

Take Note!  exual violence has been called a “tragedy of youth.” S More than half of all rapes (54%) of women occur ­before age 18 (Medicine Net, 2012). Assailants, like their victims, come from all walks of life and all ethnic backgrounds; there is no typical profile. More than half are under age 25, and the majority are married and leading “normal” sex lives. Why do men rape? No theory provides a satisfactory explanation. So few assailants are caught and convicted that a clear profile remains elusive. What is known is that many ­assailants have trouble dealing with the stresses of daily life. Such men become angry and experience feelings of powerlessness. They become jealous easily; don’t view women as equals; frequently are hot tempered; have a need to be reassured of their manhood; and do not handle stress in their lives well. They commit a sexual assault as an expression of power and control (Abbey, Wegner, Pierce & Jacques-Tiura 2012).

Sexual Abuse Sexual abuse occurs when a woman is forced to have sexual contact of any kind (vaginal, oral, or anal) without her consent. Current estimates indicate that one of five girls is sexually abused, and the peak ages of such abuse are from 8 to 12 years of age. At every age in the life span, females are more likely to be sexually abused by father, brother, family member, neighbor, boyfriend, husband, partner, or ex-partner than by a stranger or anonymous assailant. Sexual abuse knows no economic or cultural barriers (Murthy & Smith, 2010). Marriage does not constitute a tacit agreement for a spouse to inflict one’s demands on the other without permission. Childhood sexual abuse is any type of sexual exploitation that involves a child younger than 18 years old. It might include disrobing, nudity, masturbation, fondling, digital penetration, forced performance of sexual acts on the perpetrator, and intercourse (Marriott 2012). Childhood sexual abuse has a lifelong impact on its survivors. Women who were sexually abused during childhood are at a heightened risk for repeat abuse. This is because the early abuse lowers their self-esteem and their ability to protect themselves and set firm boundaries. Childhood sexual abuse is a trauma that influences the way victims form relationships, deal with adversity, cope with daily problems, relate to their children and peers, protect their health, and live. See Evidence-Based Practice 9.2 for study regarding childhood sexual abuse. Studies have shown that the more victimization a woman experiences, the more likely it is she will be revictimized (Najdowski & Ullman, 2011).

Interventions for sexually abused children or women should include referral for mental health counseling. Follow up for any medical problems (e.g., genitourinary complaints) should be arranged with the child’s or woman’s primary care physician. If the community has an abuse referral center, refer the victim there for follow-up care according to local protocol. The medical consequences of sexual abuse require the prophylaxis and treatment of sexually transmitted infections, emergency contraception, and treatment of any injuries that resulted from the abuse. Victims with post-assault bleeding require an emergent evaluation and may need emergency treatment by a gynecologist for repair of genital injury. The psychosocial aspects of sexual abuse must also be addressed because appropriate therapeutic follow-up is essential to the victim’s future emotional well-being.

Incest Incest is any type of sexual exploitation among blood relatives or surrogate relatives before the victim reaches 18 years of age. Such sexual abuse is not only a crime but also a symptom of acute and irreversible family dysfunction. Childhood incest abuse involves any kind of sexual experience between a child and another person that violates the social taboos of family roles; children cannot yet understand these activities and cannot give informed consent ( Janvier, 2010). Survivors of incest are often tricked, coerced, or manipulated. All adults appear to be powerful to children. Perpetrators might threaten victims so that they are afraid to disclose the abuse or might tell them the abuse is their fault. Often these threats serve to silence victims. Incestual relationships in the home endanger not only the child’s intellectual and moral development, but also the health of the child. Many children do not ask for help because they do not want to expose their “secret.” For this reason, just the tip of the iceberg is statistically visible: serious injuries, internal damage, sexually transmitted infections, or pregnancy. Incest can have serious long-term effects on its victims, which may include eating disorders, sexual problems in their adult life, difficulty in interpersonal relationships, anxiety, PTSD, intense guilt and shame, low self-esteem, depression, and selfdestructive behavior (National Center for Victims of Crime [NCVC], 2011a). Whether an incest victim endured an isolated incident of abuse or ongoing assaults over an extended period, recovery can be painful and difficult. The recovery process begins with admission of abuse and the recognition that help and services are needed. Resources for incest victims include books, self-help groups, workshops, therapy programs, and possibly legal remedies. In addition to listening to and believing incest victims, nurses



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EVIDENCE-BASED PRACTICE 9.2

A SEXUAL ASSAULT PRIMARY PREVENTION MODEL WITH DIVERSE URBAN YOUTH

Despite different perceptions as to what constitutes child sexual abuse, there is a consensus among clinicians and researchers that this is a substantial social problem that affects large numbers of children and young people worldwide. The effects of sexual abuse manifest themselves in a wide range of symptoms, including fear, anxiety, post-traumatic stress disorder, and behavior problems such as externalizing or internalizing, or inappropriate sexual behaviors. Child sexual abuse is associated with an increased risk of psychological problems in adulthood. By preventing sexual abuse and offering access to youth and families seeking early treatment, the lifelong symptoms of sexual abuse may be avoided.

STUDY The study hypothesis was that students who participated in the prevention project would increase their knowledge and change their beliefs regarding sexual violence and sexual harassment after completion of the program. Approval by parents and school personnel took place prior to the intervention. Due to the importance of the curriculum on school climate and sexual harassment, all students were included (there was no control group). The curriculum consisted of three presentations (60 minutes each) on three separate days, with each presentation occurring one week subsequent to the previous presentation. Statistical analyses consisted of paired sample t-tests to determine the effectiveness of the program on improving the student’s knowledge, awareness, and beliefs related to sexual violence and harassment. Multiple repeated measures ANOVAs were conducted to investigate whether there were significant differences between genders, race/ethnicity status, and grade for mean differences between the pre- and post-test total scores.

Findings The results of the study provided support regarding the components of effective prevention programs. Our findings suggest that children and adolescents can be taught healthy relationship skills that might protect them from predatory behaviors or maladaptive peer relationships. Classroom instruction can be a useful format to reach both potential victims and offenders while also reaching school staff and faculty, as they may often be in a position to report or catch early warning behaviors.

Nursing Implications The study confirms the potential for primary prevention interventions to bring about awareness of sexual assault and reduce them. It is critical that nurses and communities commit to ending the epidemic of sexual violence through preventive measures such as education. Although this intervention was shown to be effective at increasing student knowledge in certain domains, further research must continue to examine the critical factors in prevention programming. Adapted from Smothers, M., & Smothers, D. (2011). A sexual assault primary prevention model with diverse urban youth. Journal of Child Sexual Abuse, 20(6), 708–727.

need to search for ways to prevent future generations from enduring such abuse and from continuing the cycle of abuse in their own family and relationships.

Take Note! Childhood sexual abuse is a trauma that can affect every aspect of the victim’s life.

Rape Rape is an expression of violence, not a sexual act. It is not an act of lust or an overzealous release of passion: it is a violent, aggressive assault on the victim’s body and integrity. Rape is a legal rather than a medical term. It denotes penile penetration of the vagina, mouth, or rectum of the female or male without consent. It may or may not include the use of a weapon. Statutory rape is sexual activity between an adult and a person under the age of 18 and is considered to have occurred even if the underage person was willing (RAINN, 2011b). Nine out of every

A

Consider This

t 53  years old, I stood and looked at myself in the mirror. The image staring back at me was one of a frightened, middle-aged, cowardly woman hiding her past. I had been sexually abused by my father for many years as a child and never told anyone. My mother knew of the abuse but felt helpless to make it stop. I married right out of high school to escape and felt I lived a “happy normal life” with my husband and three children. My children have left home and live away, and my husband recently died of a sudden heart attack. I am now experiencing dreams and thoughts about my past abuse and feeling afraid again. Thoughts: This woman suppressed her abusive past for most of her life and now her painful experience has surfaced. What can be done to reach out to her at this point? Did her health care providers miss the “red flags” that are common to women with a history of childhood sexual abuse all those years?

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10 rape victims are female (Alexander, LaRosa, Bader, & Garfield, 2010). Enforcement of laws, education, and community empowerment are all needed to prevent rape. Many people believe that rape usually occurs on a dark night when a stranger assaults a provocatively dressed, promiscuous woman. They believe that rapists are sex-starved people seeking sexual gratification. Rape myths are destructive beliefs about sexual aggression (i.e., its scope, causes, context, and consequences) that serve to deny, downplay, or justify sexually aggressive behavior that men commit against women. (McGee, O’Higgins, Garavan, & Conroy 2011) Rape myths serve to blame victims and exonerate perpetrators. Such myths and the facts are presented in Table 9.2.

Acquaintance Rape In acquaintance rape, someone is forced to have sex by a person he or she knows. Rape by a coworker, a teacher, a husband’s friend, or a boss is considered acquaintance rape. Date rape, an assault that occurs within a dating relationship or marriage without consent of one of the participants, is a form of acquaintance rape. Acquaintance and date rapes commonly occur on college campuses.

­ TABLE 9.2

One in four college women has been raped—that is, has been forced, physically or verbally, actively or implicitly, to engage in sexual activity (Testa & Hoffman 2012). These forms of rape are physically and emotionally devastating for the victims. Research has indicated that the survivors of acquaintance rape report similar levels of depression, anxiety, complications in subsequent relationships, and difficulty attaining pre-rape levels of sexual satisfaction to those reported by survivors of stranger rape. Acquaintance rape remains a controversial topic because there is lack of agreement on the definition of consent. Despite the violation and reality of physical and emotional trauma, victims of acquaintance assault often do not identify their experience as sexual assault. Instead of focusing on the violation of the sexual assault, victims of acquaintance rape often blame themselves for the assault (RAINN, 2011a). Although acquaintance rape and date rape do not always involve drugs, a rapist might use alcohol or other drugs to sedate his victim. In 1996 the federal government passed a law making it a felony to give an unsuspecting person a “date rape drug” with the intent of raping him or her. Even with penalties of large fines and up to 20 years in prison, the use of date rape drugs is growing (USDHHS, 2010a).

COMMON MYTHS AND FACTS ABOUT RAPE

Myths

Facts

Women who are raped get over it quickly.

It can take several years to recover emotionally and physically from rape.

Most rape victims tell someone about it.

The majority of women never tell anyone about it. In fact, almost two thirds of victims never report it to the police.

Once the rape is over, a survivor can again feel safe in her life.

The victim feels vulnerable, betrayed, and insecure afterward.

If a woman does not want to be raped, it cannot happen.

A woman can be forced and overpowered by most men.

Women who feel guilty after having sex then say they were raped.

Few women falsely cry “rape.” It is very traumatizing to be a victim.

Victims should report the violence to the police and judicial system.

Only 1% of rapists are arrested and convicted.

Women blame themselves for the rape, believing they did something to provoke the rape.

Women should never blame themselves for being the victim of someone else’s violence.

Women who wear tight, short clothes are “asking for it.”

No victim invites sexual assault, and what she wears is irrelevant.

Women have rape fantasies and want to be raped.

Reality and fantasy are different. Dreams have nothing to do with the brutal violation of rape.

Medication can help women forget about the rape.

Initially medication can help, but counseling is needed.

Adapted from Centers for Disease Control and Prevention [CDC]. (2011b). Sexual violence: Fact sheet. National Center for Injury Prevention and Control. Retrieved from http://www.cdc.gov/ ncipc/factsheets/svfacts.htm; Medicine Net. (2012). Sexual assault. Retrieved from http://www.­ medicinenet.com/script/main/ art.asp?articlekey=46498& pf=3; and Milone, J. M., Burg, M., Duerson, M. C., Hagen, M. G., & Pauly, R. R. (2010). The Effect of Lecture and a Standardized Patient Encounter on Medical Student Rape Myth Acceptance and Attitudes Toward Screening Patients for a History of Sexual Assault. Teaching & Learning In Medicine, 22(1), 37–44.



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Date rape drugs are also known as “club drugs” because they are often used at dance clubs, fraternity parties, and all-night raves. The most common is Rohypnol (also known as “roofies,” “forget pills,” and the “drop drug”). It comes in the form of a liquid or pill that quickly dissolves in liquid with no odor, taste, or color. This drug is 10 times as strong as diazepam (Valium) and produces memory loss for up to 8  hours. Gamma hydroxybutyrate (GHB; called “liquid ecstasy” or “easy lay”) produces euphoria, an out-of-body high, sleepiness, increased sex drive, and memory loss. It comes in a white powder or liquid and may cause unconsciousness, depression, and coma. The third date rape drug, ketamine (known as “Special K,” “vitamin K,” or “superacid”), acts on the central nervous system to separate perception and sensation. Combining ketamine with other drugs can be fatal. Date rape drugs can be very dangerous, and women can protect themselves against them in a variety of ways (Teaching Guidelines 9.2).

Teaching Guidelines 9.2 PROTECTING YOURSELF AGAINST DATE RAPE DRUGS • Avoid parties where alcohol is being served. • Never leave a drink of any kind unattended. • Don’t accept a drink from someone else. Accept drinks from a bartender or in a closed container only. • Don’t drink from a punch bowl or a keg. • If you think someone drugged you, call 911.

­ TABLE 9.3

Rape Recovery Rape survivors take a long time to heal from their traumatic experience. Some women never heal and never get professional counseling, but most can cope. Rape is viewed as a situational crisis that the survivor is unprepared to handle because it is an unforeseen event. Survivors typically go through four phases of recovery following rape (Table 9.3). A significant proportion of women who are raped also experience symptoms of post-traumatic stress disorder (PTSD). PTSD develops when an event outside the range of normal human experience occurs that produces marked distress in the person. Symptoms of PTSD are divided into three groups: • Intrusion (reexperiencing the trauma, including nightmares, flashbacks, recurrent thoughts) • Avoidance (avoiding trauma-related stimuli, social withdrawal, emotional numbing) • Hyperarousal (increased emotional arousal, exaggerated startle response, irritability) Not every traumatized female develops full-blown or even minor PTSD. Symptoms usually begin within 3  months of the incident, but occasionally may only emerge years later. They must last more than a month to be considered PTSD. The condition varies from person to person. Some women recover within months, while others have symptoms for much longer. In some people, the condition becomes chronic (Littleton, Buck, Rosman & Grills-Taquechel 2012).

FOUR PHASES OF RAPE RECOVERY

Phase

Survivor’s Response

Acute phase (disorganization)

Shock, fear, disbelief, anger, shame, guilt, feelings of uncleanliness; insomnia, nightmares, and sobbing

Outward adjustment phase (denial)

Appears outwardly composed and returns to work or school; r­ efuses to discuss the assault and denies need for counseling

Reorganization

Denial and suppression do not work, and the survivor attempts to make life adjustments by moving or changing jobs and uses emotional distancing to cope.

Integration and recovery

Survivor begins to feel safe and starts to trust others. She may become an advocate for other rape victims.

Adapted from Fahs, B. (2011). Sexual violence, disidentification, and long-term trauma recovery: A process-oriented case study analysis. Journal of Aggression, Maltreatment & Trauma, 20(5), 556–578; National Center for Victims of Crime [NCVC]. (2011b). Rape-related post-traumatic stress disorder. Retrieved from http://www.ncvc.org/ncvc/main.aspx?dbName=DocumentViewer& DocumentID=32366; and Rape, Abuse, and Incest National Network [RAINN]. (2011d). Recovery from sexual assault. Retrieved from http://www.rainn.org/get-information/sexual-assault-recovery.

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Nursing Management of Rape Victims Research has found that rape survivors undergo a ­profound and complex trauma. The survivor should be provided with a safe and comfortable environment for a forensic ­examination. Nursing care of the rape survivor should ­focus on providing supportive care, collecting and documenting evidence, assessing for sexually transmitted

infections, preventing pregnancy, and ­assessing for PTSD. Once initial treatment and evidence collection have been completed, follow-up care should include counseling, medical treatment, and crisis intervention. There is mounting evidence that early intervention and immediate ­counseling speed a rape survivor’s recovery. Nursing Care Plan 9.1 highlights a sample plan of care for a victim of rape.

NURSING CARE PLAN 9.1

Overview of the Woman Who is a Victim of Rape Lucia, a 20-year-old college junior, was admitted to the emergency room after police found her when a passerby called 911 to report an assault. She stated, “I was raped a few hours ago while I was walking home through the park.” Assessment reveals the following: numerous cuts and bruises of varying sizes on her face, arms, and legs; lip swollen and cut; right eye swollen and bruised; jacket and shirt ripped and bloodied; hair matted with grass and debris; vital signs within acceptable parameters; client tearful, clutching her clothing, and trembling; perineal bruising and tearing. NURSING DIAGNOSIS: Rape-trauma syndrome related to report of recent sexual assault Outcome Identification and Evaluation

Client will demonstrate adequate coping skills related to effects of rape as evidenced by her ability to discuss the event, verbalize her feelings and fears, and exhibit appropriate actions to return to her pre-crisis level of functioning. Interventions: Promoting Adequate Coping Skills

• Stay with the client to promote feelings of safety. • Explain the procedures to be completed based on facility’s policy to help alleviate client’s fear of the unknown. • Assist with physical examination for specimen collection to obtain evidence for legal proceedings. • Administer prophylactic medication as ordered to prevent pregnancy and sexually transmitted infections. • Provide care to wounds as ordered to prevent infection. • Assist client with hygiene measures as necessary to promote self-esteem. • Allow client to describe the events as much as possible to encourage ventilation of feelings about the incident; engage in active listening and offer nonjudgmental support to facilitate coping and demonstrate understanding of the client’s situation and feelings.

• Help the client identify positive coping skills and personal strengths used in the past to aid in effective decision making. • Assist client in developing additional coping strategies and teach client relaxation techniques to help deal with the current crisis and anxiety. • Contact the rape counselor in the facility to help the client deal with the crisis. • Arrange for follow-up visit with rape counselor to provide continued care and to promote continuity of care. • Encourage the client to contact a close friend, partner, or family member to accompany her home to provide support. • Provide the client with the telephone number of a counseling service or community support groups to help her cope and obtain ongoing support. • Provide written instructions related to follow­up appointments, care, and testing to ensure adequate understanding.



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Take Note! Many rape survivors seek treatment in the hospital emergency department if no rape crisis center is available. Unfortunately, many emergency department doctors and nurses have little training in how to treat rape survivors or in collecting evidence. To make matters worse, if they have to wait for hours in public waiting rooms, survivors may leave the hospital, never to receive treatment or supply the evidence needed to arrest and convict their assailants. PROVIDING SUPPORTIVE CARE Establishing a therapeutic and trusting relationship will help the survivor describe her experience. Take the woman to a secure, isolated area away from family, friends, and other clients and staff so she can be open and honest when asked about the assault. Provide a change of clothes, access to a shower and toiletries, and a private waiting area for family and friends. COLLECTING AND DOCUMENTING EVIDENCE The victim should be instructed to bring all clothing, especially undergarments, worn at the time of the assault to the medical facility. The victim should not shower or bathe before presenting for care. Typically a specially trained nurse will collect the evidence from the victim. ASSESSING FOR SEXUALLY TRANSMITTED INFECTIONS As part of the assessment, a pelvic examination will be done to collect vaginal secretions to rule out any sexually transmitted infections. This examination is very emotionally stressful for most women and should be carried out very gently and sensitively. PREVENTING PREGNANCY An essential element in the care of rape survivors involves offering them pregnancy prevention. After unprotected intercourse, including rape, pregnancy can be prevented by using an emergency contraceptive pill, sometimes called postcoital contraception. Emergency contraceptive pills involve high doses of the same oral contraceptives that millions of women take every day. The emergency regimen consists of one dose taken within 72 to 120 hours of the unprotected intercourse. Emergency contraception works by preventing ovulation, fertilization, or implantation. It does not disrupt an established pregnancy and should not be confused with mifepristone (RU-486), a drug approved by the Food and Drug Administration for abortion in the first 49 days of gestation. Emergency contraception is most effective if is taken within 12 hours of the rape; it becomes less effective with every 12 hours of delay thereafter.

ASSESSING FOR PTSD Nurses can begin to assess the extent to which a survivor is suffering from PTSD by asking the following questions: • To assess the presence of intrusive thoughts: • Do upsetting thoughts and nightmares of the trauma bother you? • Do you feel as though you are actually reliving the trauma? • Does it upset you to be exposed to anything that reminds you of that event? • To assess the presence of avoidance reactions: • Do you find yourself trying to avoid thinking about the trauma? • Do you stay away from situations that remind you of the event? • Do you have trouble recalling exactly what happened? • Do you feel numb emotionally? • To assess the presence of physical symptoms: • Are you having trouble sleeping? • Have you felt irritable or experienced outbursts of anger? • Do you have heart palpitations and sweating? • Do you have muscle aches and pains all over? (NCVC, 2011b) With a growing body of knowledge about rape-­ related PTSD, help is available through most rape crisis and trauma centers. Support groups have been established where survivors can meet regularly to share experiences to help relieve the symptoms of PTSD. For some survivors, medication prescribed along with therapy is the best combination to relieve the pain. Just as in the treatment of any other illness, at the first opportunity, the woman should be encouraged to talk about the traumatic experience. This ventilating provides a chance to receive needed support and comfort, as well as an opportunity to begin making sense of the experience. To diminish symptoms of PTSD, survivors must work on two fronts: coming to terms with the past and alleviating stress in the present (Freedy & Brock, 2010).

Female Genital Cutting Female genital cutting (FGC), also referred to as female genital mutilation (FGM) or female circumcision, is defined as a procedure involving any injury of the external female genitalia for cultural or nontherapeutic reasons (Sandy, 2011). It is the surgical removal of a portion or portions of the genitalia of female infants, girls, and women, including the clitoris (type I), clitoris and labia minora (type II), and clitoris, labia minora, labia majora, and then suturing of the remaining tissue, known as fibulation, to leave only a small opening for urination, menstruation, intercourse, and childbirth (type III). There is a type IV, which encompasses all other mutilations of the

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female genital area such as pricking, piercing, cutting, and scraping of the vaginal tissue, incisions to the clitoris and vagina, and burning, scarring, or cauterizing of tissue with the aim of tightening or narrowing the vagina (Murthy & Smith, 2010). Female genital cutting is a worldwide practice that affects millions of women and girls. According to the World Health Organization (WHO) (2012) and UNICEF, 140 million women are victims of female genital cutting with about 1  million girls between infancy and age  15 undergoing FGC every year. Countries where this is practiced include 28 African countries and parts of the Middle East and Asia (Blanton, 2011). The exact origins of FGC are not known. Although FGC may be interwoven into the culture, it is not mandated by any religion. This practice predates both Islam and Christianity (Blanton, 2011). In some cultures, it is associated with feminine beauty and often signifies a rite of passage from childhood to adulthood. Female cutting is performed to decrease a woman’s sexual desires and to ensure her chastity until marriage and receipt of a dowry from the prospective groom (Wade, 2011). Ultimately, the reality of being ostracized by the community and the possibility of being ineligible to marry create enormous social pressure to have FGC carried out, pressure that outweighs the known physical and emotional damage of this practice (Sandy, 2011). Complications vary, depending on the type of cutting and the way it was performed. It is frequently performed without anesthesia under nonsterile conditions. Cutting tools can be anything from razors blades to knives to pieces of glass. Complications can include infertility, dysmenorrhea, dyspareunia, sexual dysfunction, infection, hemorrhage after the procedure, vaginal stenosis, chronic vaginitis, pelvic inflammatory disease, chronic urinary tract infections, incontinence, genital fistulas, recurrent abscesses, transmission of HIV and hepatitis during the procedure, severe pain and shock after the procedure, difficulty walking or using stairs due to severe scarring, urinary retention, inability to experience orgasm, and difficulty in giving birth The psychological effects range from eating disorders, insomnia, depression, PTSD, and negative effects on the women’s self-esteem and identity (Chibber, El-Saleh, & El Harmi, 2011). As immigration to the United States increases, nurses are increasingly likely to encounter women affected by female genital cutting and its complications. The psychological pressure and trauma of being torn between two cultures and feeling different may lay heavily on the women in a new setting where FGC is foreign and banned. Nurses need updated education regarding women with female genital cutting so that appropriate care for this population can be provided for this very sensitive health care problem. Well-informed nurses are the best tool for providing culturally sensitive care to this population.

Take Note! From a Western perspective, female genital cutting is hard to comprehend. Because it is not talked about openly in communities that practice it, women who have undergone it accept it without question and assume it is done to all girls (Bui 2012).

Background Reasons for performing the ritual reflect the ideology and cultural values of each community that practices it. Some consider it a rite of passage into womanhood; others use it as a means of preserving virginity until marriage. In cultures where it is practiced, it is an important part of culturally defined gender identity. In any case, all the reasons are cultural and traditional and are not rooted in any religious texts (Research Action and Information Network for the Bodily Integrity of Women, 2010). Box  9.6 lists types of female genital cutting procedures.

Nursing Management of Female Genital Cutting Client Because of increasing migration, nurses throughout the world are increasingly exposed to women who have experienced these procedures and thus need to know

BOX 9.6

FOUR MAJOR TYPES OF FEMALE GENITAL MUTILATION PROCEDURES Type I: Excision of the prepuce with ­excision of part or the entire clitoris Type II: Excision of the clitoris and part or all of the labia minora Type III (Infibulation): Excision of all or part of the external genitalia and stitching/narrowing of the v­ aginal opening Type IV: Pricking, piercing, or incision of the clitoris or labia • Stretching of the clitoris and/or labia • Cauterizing by burning the clitoris and surrounding tissues • Scraping or cutting the vaginal orifice • Introduction of a corrosive substance into the vagina • Placing herbs into the vagina to narrow it Adapted from Bui, H. (2012). Review of transcultural bodies: Female genital cutting in global context. Culture, Health & Sexuality, 14(4), 463-465. Sandy, H. (2011). Female genital cutting: An overview. American Journal for Nurse Practitioners, 15(1–2), 53–59; and World Health Organization [WHO]. (2012). Female genital mutilation. Retrieved from http://www.who.int/mediacentre/factsheets/fs241/en/print.html.



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about its impact on women’s reproductive health. Helping women who have had a FGC procedure requires good communication skills and often an interpreter, since many may not speak English. As nurses, we are educated to provide comprehensive, culturally sensitive care regardless of our client’s circumstances. Nurses have the opportunity to educate clients by providing accurate information and positive health care experiences. Make sure that you are comfortable with your own feelings about this practice before dealing with clients. Some guidelines are as follows: • Let the client know you are concerned and interested and want to help. • Speak clearly and slowly, using simple, accurate terms. • Use the term or name for this practice that the recipient uses, not “female genital cutting.” • Use pictures and diagrams to help the woman understand what you are saying. • Be patient in allowing the client to answer questions. • Repeat back your understanding of the client’s statements. • Always look and talk directly to the client, not the interpreter. • Place no judgment on the cultural practice. • Encourage the client to express herself freely. • Maintain strict confidentiality. • Provide culturally attuned care to all women.

what appear to be legitimate sources find themselves in situations where their documents are destroyed, their selves or their families threatened with harm, or they are bonded by a debt that they have no chance of repaying Trafficking persons is hugely profitable: one estimate places global profits at approximately $35 ­billion annually. Among illegal enterprises, trafficking is second only to drug dealing and is tied with the illegal arms industry in its ability to generate dollars ­(Walters 2012). The United States is a profitable destination country for traffickers, and these profits contribute to the development of organized criminal enterprises worldwide. According to findings of the Victims of Trafficking and Violence Protection Act of 2000: • Victims are primarily women and children who lack education, employment, and economic opportunities in their own countries. • Traffickers promise victims employment as nannies, maids, dancers, factory workers, sales clerks, or models in the United States. • Traffickers transport the victims from their counties to unfamiliar destinations away from their support systems. • Once they are here, traffickers coerce them, using rape, torture, starvation, imprisonment, threats, or physical force, into prostitution, pornography, the sex trade, forced labor, or involuntary servitude.

Human Trafficking

These victims are exposed to serious and numerous health risks, such as rape, torture, HIV/AIDS, sexually transmitted infections, cervical cancer, violence, hazardous work environments, poor nutrition, and drug and alcohol addiction (Logan, Walker, & Hunt, 2010). Health care is one of the most pressing needs of these victims, but no comprehensive care is available to undocumented immigrants. Nurses and other health care providers who encounter victims of trafficking often do not realize it, and opportunities to intervene are lost. Although no one sign can demonstrate with certainty when someone is being trafficked, clinicians should be aware of several indicators. It is important to be alert for trafficking victims in any setting and to recognize cues (Box 9.7). Nursing interventions in the case of trafficking victims would include the following: • Building trust is the number-one priority • Reassure the potential victim • One-on-one interactions are ideal • Specifically ask about the client’s safety • Offer reworded stories • Stay calm and on an even keel • ALWAYS document your suspicion in your notes, at the very least • Call the human trafficking hotline for guidance: 1-866-US-TIPLINE

A girl who was just 14 years old was held captive in a tiny trailer room, where she was forced to have sex with as many as 30 men a day. On her nightstand was a teddy bear that reminded her of her childhood in Mexico. This scenario describes human trafficking, the enslavement of immigrants for profit in America. Within our borders, thousands of foreign nationals and U.S. citizens, many of them children, are forced or coerced into sex work or various forms of labor every year (Sabella, 2011). Human trafficking is both a global problem and a domestic problem. The United States is a major receiver of trafficked persons. Human trafficking is a modern form of slavery that affects nearly 1  million people worldwide and approximately 20,000 persons in the United States annually (U.S. Department of State, 2010). Women and children are the primary victims of human trafficking, many in the sex trade as described above and others through forced-labor domestic servitude. Poverty and lack of economic opportunity make women and children potential victims of traffickers associated with international criminal organizations. They are vulnerable to false promises of job opportunities in other countries. Many of those who accept these offers from

300   U N I T 2   Women’s Health Throughout the Life Span BOX 9.7

IDENTIFYING VICTIMS OF HUMAN TRAFFICKING Look beneath the surface and ask yourself: Is this person. • A female or a child in poor health? • Foreign-born and doesn’t speak English? • Lacking immigration documents? • Giving an inconsistent explanation of injury? • Reluctant to give any information about self, injury, home, or work? • Fearful of authority figure or “sponsor” if present? (“Sponsor” might not leave victim alone with health care provider.) • Living with the employer? Sample questions to ask the potential victim of human trafficking: • Can you leave your job or situation if you wish? • Can you come and go as you please? • Have you been threatened if you try to leave? • Has anyone threatened your family with harm if you leave? • What are your working and living conditions? • Do you have to ask permission to go to the bathroom, eat, or sleep? • Is there a lock on your door so you cannot get out? • What brought you to the United States? Are your plans the same now? • Are you free to leave your current work or home situation? • Who has your immigration papers? Why don’t you have them? • Are you paid for the work you do? • Are there times you feel afraid? • How can your situation be changed? Adapted from Walters, S. (2012). Review of ‘sex trafficking: Inside the business of modern slavery’. Culture, Health & Sexuality, 14(1), 121-123. Logan, T. K., Walker, R., & Hunt, G. (2010). Understanding human trafficking in the United States. Trauma, Violence & Abuse, 10(1), 3–30; Murthy, P., & Smith, C. L. (2010). Women’s global health and human rights. Sudbury, MA: Jones & Bartlett; and Sabella, D. (2011). The role of the nurse in combating human trafficking. American Journal of Nursing, 111(2), 28–39.

Human trafficking is a violation of human rights. Few crimes are more repugnant than the sex trafficking of helpless and innocent victims. If you suspect a trafficking situation, notify local law enforcement and a regional social service organization that has experience in dealing with trafficking victims. It is imperative to reach out to these victims and stop the cycle of abuse by following through on your suspicions.

SUMMARY The causes of violence against women are complex. Many women will experience some type of violence in their lives, and it can have a debilitating affect on their health and future relationships. Violence frequently leaves a “legacy of pain” to future generations. Nurses can empower women and encourage them to move forward and take control of their lives. When women live in peace and security, free from violence, they have an enormous potential to contribute to their own communities and to the national and global society. Violence against women is not normal, legal, or acceptable and it should never be tolerated or justified. It can and must be stopped by the entire world community.

KEY CONCEPTS Violence against women is a major public health and social problem because it violates a woman’s very being and causes numerous mental and physical health sequelae. Every woman has the potential to become a victim of violence. Several Healthy People 2020 objectives focus on reducing the rate of physical assaults and the number of rapes and attempted rapes. Abuse may be mental, physical, or sexual in nature or a combination. The cycle of violence includes three phases: tension building, acute battering, and honeymoon. Many women experience post-traumatic stress disorder (PTSD) after being sexually assaulted. PTSD can inhibit a survivor from adapting or coping in a healthy manner. Pregnancy can precipitate violence toward the woman or escalate it. Female genital cutting is practiced worldwide and nurses in the United States need to become knowledgeable about it and place no judgment on this cultural practice. Human trafficking is a violation against human rights, and nurses who suspect it should report it to stop the cycle of abuse against young children and women. The nurse’s role in dealing with survivors of violence is to establish rapport; open up lines of communication; apply the nursing process to assess and screen all clients in all settings; and implement and intervene as appropriate.



References Abbey, A., Wegner, R., Pierce, J., & Jacques-Tiura, A. J. (2012). Patterns of sexual aggression in a community sample of young men: Risk factors associated with persistence, desistance, and initiation over a 1-year interval. Psychology Of Violence, 2(1), 1–15. Abramsky, T., Watts, C. H., Garcia-Moreno, C., Devries, K., Kiss, L., ­Ellsberg, M., . . . Heise, L. (2011). What factors are associated with recent intimate partner violence? Findings from the WHO multi-­ country study on women’s health and domestic violence. BMC ­Public Health, 11(1), 109–125. ACOG Committee Opinion No. 518: Intimate partner violence. (2012). Obstetrics and Gynecology, 119(2 Pt 1), 412–417. Aggeles, T. B. (2012). Domestic violence advocacy, Florida, update. Retrieved from http://ce.nurse.com/60133/CoursePage Alexander, L. L., LaRosa, J. H., Bader, H., & Garfield, S. (2010). New dimensions in women’s health (5th ed.). Sudbury, MA: Jones & Bartlett. Ard, K., & Makadon, H. (2011). Addressing intimate partner violence in lesbian, gay, bisexual, and transgender patients. Journal of General Internal Medicine, 26(8), 930–933. Association of Women’s Health, Obstetric and Neonatal Nurses. (2010). Violence against women: Identification, screening and management of intimate partner violence. Retrieved from http://www .awhonn.org Barner, J., & Carney, M. (2011). Interventions for intimate partner violence: A historical review. Journal of Family Violence, 26(3), 235–244. Blanton, K. (2011). Female genital cutting and the health care provider’s dilemma: A case study. Clinical Scholars Review, 4(2), 119–124. Brownridge, D. A., Tallieu, T. L., Tyler, K. A., Tiwari, A., Chan, K. L., & ­Santos, S. C. (2011). Pregnancy and intimate partner violence: Risk factors, severity, and health effects. Violence Against Women, 17(7), 858–881. Bui, H. (2012). Review of transcultural bodies: Female genital cutting in global context. Culture, Health & Sexuality, 14(4), 463–465. Burnett, L. B., & Adler, J. (2011). Domestic violence. eMedicine. Retrieved from http://emedicine.medscape.com/article/805546-overview Caldwell, J.E., Swan, S.C., & Woodbrown, V.D. (2012) Gender differences in intimate partner violence outcomes. Psychology of Violence. 2(1), 42–57. Centers for Disease Control and Prevention [CDC]. (2011a). Intimate partner violence during pregnancy. Retrieved from http://www.cdc .gov/reproductivehealth/violence/IntimatePartnerViolence/index.htm Centers for Disease Control and Prevention [CDC]. (2011b). Sexual violence: Fact sheet. National Center for Injury Prevention and Control. Retrieved from http://www.cdc.gov/ ncipc/factsheets/svfacts.htm Centers for Disease Control and Prevention [CDC]. (2012). Understanding intimate partner violence. National Center for Injury Prevention and Control. Retrieved from http://www.cdc.gov/violenceprevention/ pdf/ipv_factsheet-a.pdf Chibber, R., El-Saleh, E., & El Harmi, J. (2011). Female circumcision: Obstetrical and psychological sequelae continues unabated in the 21st century. Journal of Maternal–Fetal & Neonatal Medicine, 24(6), 833–836. Chu, S., Goodwin, M., & D’Angelo, D. (2010). Physical violence against United States women around the time of pregnancy. American Journal of Preventive Medicine, 38(3), 317–322. Cleverley, K., & Boyle, M. (2010). The individual as a moderating agent of the long-term impact of sexual abuse. Journal of Interpersonal Violence, 25(2), 274–290. Cronholm, P., Fogarty, C., Ambuel, B., & Harrison, S. (2011). Intimate partner violence. American Family Physician, 83(10), 1165–1172. Desmarais, S.L., Reeves, K.A., Nicholls, T.L., Telford, R.P., & Fiebert, M.S. (2012) Prevalence of physical violence in intimate relationships: Rates of male and female perpetration. Partner Abuse. 3(2), 170–198. Fahs, B. (2011). Sexual violence, disidentification, and long-term trauma recovery: A process-oriented case study analysis. Journal of Aggression, Maltreatment & Trauma, 20(5), 556–578. Fairweather, L. (2012) Stop signs: Recognizing, avoiding and escaping abusive relationships. Berkeley, CA: Seal Press. Federal Bureau of Investigation [FBI]. (2011). Intimate partner violence. Retrieved from http://www.ojp.usdoj.gov/bjs/pub/ascii/ipv.txt. Fowler, K. A., & Westen, D. (2011). Subtyping male perpetrators of intimate partner violence. Journal of Interpersonal Violence, 26(4), 607–639. Freedy, J. R., & Brock, C. D. (2010). Spotting and treating PTSD in primary care. Journal of Family Practice, 59(2), 75–80. Garboden, M. (2010). Model response to domestic violence. Community Care (1800), 22–23.

C h a p t e r 0 9  Violence and Abuse   301 Hawley, D. A., & Hawley-Barker, A.C. (2012). Survivors of intimate partner violence: Implications for nursing care. Critical Care Nursing Clinics Of North America, 24(1), 27–39 Holtz, H., & Furniss, K. K. (1993). The health care provider’s role in domestic violence. Trends in Health Care Law and Ethics, 15, 519–522. Howard, L.M. (2012) Domestic violence: It relevance to psychiatry. Advances in Psychiatric Treatment. 18(3), 129–136. Jankowski, P. J., Johnson, A. J., Holtz Damron, J. E., & Smischney, T. (2011). Religiosity, intolerant attitudes, and domestic violence myth acceptance. International Journal for the Psychology of Religion, 21(3), 163–182. Janvier, A. (2010). Commentary. Hastings Center Report, 14. Retrieved from Health Source: Nursing/Academic Edition database. Joint Commission. (2010). The Joint Commission accreditation manual for hospitals. Chicago: Author. Kiely, M., El-Mohandes, A., El-Khorazaty, M., & Gantz, M. (2010). An integrated intervention to reduce intimate partner violence in pregnancy: A randomized controlled trial. Obstetrics and Gynecology, 115(2), 273–283. Kruse, M., Sørensen, J., Brønnum-Hansen, H., & Helweg-Larsen, K. (2011). The health care costs of violence against women. Journal of Interpersonal Violence, 26(17), 3494–3508. Lamers-Winkelman, F., Willemen, A.M., & Visser, M. (2012) Adverse childhood experiences of children exposed to intimate partner violence: Consequences of their wellbeing. Child Abuse & Neglect. 36(2), 166–179. Littleton, H., Buck, K., Rosman, L., & Grills-Taquechel, A. (2012). From survivor to thriver: A pilot study of an online program for rape victims. Cognitive And Behavioral Practice, 19(2), 315–327. Logan, T. K., Walker, R., & Hunt, G. (2010). Understanding human trafficking in the United States. Trauma, Violence & Abuse, 10(1), 3–30. March of Dimes. (2011). Abuse during pregnancy. Retrieved from http://www.marchofdimes.com/pregnancy/stayingsafe_abuse.html Marriott, S. (2012). Trauma: memories of childhood sexual abuse. Practising Midwife, 15(2), 22–24. McGee, H., O’Higgins, M., Garavan, R., & Conroy, R. (2011). Rape and Child Sexual Abuse: What Beliefs Persist About Motives, Perpetrators, and Survivors?. Journal Of Interpersonal Violence, 26(17), 3580–3593. Medicine Net. (2012). Sexual assault. Retrieved from http://www .medicinenet.com/script/main/ art.asp?articlekey=46498&pf=3 Milone, J. M., Burg, M., Duerson, M. C., Hagen, M. G., & Pauly, R. R. (2010). The Effect of Lecture and a Standardized Patient Encounter on Medical Student Rape Myth Acceptance and Attitudes Toward Screening Patients for a History of Sexual Assault. Teaching & Learning In Medicine, 22(1), 37–44. Murthy, P., & Smith, C. L. (2010). Women’s global health and human rights. Sudbury, MA: Jones & Bartlett. Najdowski, C. J., & Ullman, S. E. (2011). The effects of revictimization on coping and depression in female sexual assault victims. Journal of Traumatic Stress, 24(2), 218–221. National Center for Victims of Crime [NCVC]. (2011a). Incest. Retrieved from http://www.ncvc.org/ncvc/main.aspx?dbName=DocumentVie wer&DocumentID=32360 National Center for Victims of Crime [NCVC]. (2011b). Rape-­related post-traumatic stress disorder. Retrieved from http://www.ncvc. org/ncvc/main.aspx?dbName=DocumentViewer&Document ID=32366 National Center on Elder Abuse. (2011). NCEA fact sheet: Elder abuse prevalence and incidence. Retrieved from http://www.ncea.aoa.gov/ ncearoot/Main_Site/pdf/publication/FinalStatistics050331.pdf Rape, Abuse, and Incest National Network [RAINN]. (2011a). Acquaintance rape. Retrieved from http://www.rainn.org/get-information/ types-of-sexual-assault/acquaintance-rape Rape, Abuse, and Incest National Network [RAINN]. (2011b). Child sexual abuse. Retrieved from http://www.rainn.org/get-information/ types-of-sexual-assault/child-sexual-abuse Rape, Abuse, and Incest National Network [RAINN]. (2011c). RAINN statistics. Retrieved from http://www.rainn.org/statistics.html. Rape, Abuse, and Incest National Network [RAINN]. (2011d). Recovery from sexual assault. Retrieved from http://www.rainn.org/ get-information/sexual-assault-recovery Research Action and Information Network for the Bodily Integrity of Women. (2010). Caring for women with circumcision: Fact sheet for physicians. Retrieved from http://www.rainbo.org/factsheet.html.

302   U N I T 2   Women’s Health Throughout the Life Span Riggs, S. (2010). Childhood emotional abuse and the attachment system across the life cycle: What theory and research tell us. Journal of Aggression, Maltreatment & Trauma, 19(1), 5–51. Sabella, D. (2011). The role of the nurse in combating human trafficking. American Journal of Nursing, 111(2), 28–39. Sandy, H. (2011). Female genital cutting: An overview. American Journal for Nurse Practitioners, 15(1–2), 53–59. Scott-Tilley, D., Tilton, A., & Sandel, M. (2010). Biologic correlates to the development of post-traumatic stress disorder in female victims of intimate partner violence: Implications for practice. Perspectives in Psychiatric Care, 46(1), 26–36. Smothers, M., & Smothers, D. (2011). A sexual assault primary prevention model with diverse urban youth. Journal of Child Sexual Abuse, 20(6), 708–727. Soria, S. (2011). Screening for intimate partner violence in the ambulatory care setting. AAACN Viewpoint, 33(3), 1–3. Spohn, C., & Tellis, K. (2012). The criminal justice system’s response to sexual violence. Violence Against Women, 18(2), 169–192. Steen, M., & Keeling, J. (2012). Stop! Silence screams. Practising Midwife, 15(2), 28–30. Tetterton, S., & Farnsworth, E. (2011). Older women and intimate partner violence: Effective interventions. Journal of Interpersonal Violence, 26(14), 2929–2942. Testa, M., & Hoffman, J. (2012). Naturally occurring changes in women’s drinking from high school to college and implications for sexual victimization. Journal of Studies on Alcohol and Drugs, 73(1), 26–33. Todahl, J., & Walters, E. (2011). Universal screening for intimate partner violence: A systematic review. Journal of Marital & Family Therapy, 37(3), 355–369.

Trevillion, K. (2011). Domestic violence: Responding to the needs of patients. Nursing Standard, 25(26), 48–56. U.S. Department of Health and Human Services [USDHHS]. (2010a). Frequently asked questions about date rape drugs. National Women’s Health Information Center. Retrieved from http://www.4woman. gov/faq/rohypnol.pdf. U.S. Department of Health and Human Services [USDHHS]. (2010b). Healthy People 2020. Retrieved from Retrieved from http://www.healthypeople.gov/document/HTML/Volume2/15Injury.htm#_Toc490549392 U.S. Department of State. (2010). Trafficking in persons report (Publication No. 11057, p. 7). Washington, DC: Author. Vatnar, S., & Bjørkly, S. (2010). Does it make any difference if she is a mother? An interactional perspective on intimate partner violence with a focus on motherhood and pregnancy. Journal of Interpersonal Violence, 25(1), 94–110. Victims of Trafficking and Violence Protection Act of 2000, Pub. Law No. 106-386 [H.R. 3244] (2000). Retrieved from http://ojp.gov/vawo/ laws/vawo2000/stitle_a.htm. Wade, L. (2011). The politics of acculturation: Female genital cutting and the challenge of building multicultural democracies. Social Problems, 58(4), 518–537. Walters, S. (2012). Review of ‘sex trafficking: Inside the business of modern slavery’. Culture, Health & Sexuality, 14(1), 121–123. World Health Organization [WHO]. (2011). Violence against women. Retrieved from http://www.who.int/mediacentre/factsheets/fs239/ en/index.html World Health Organization [WHO]. (2012). Female genital mutilation. Retrieved from http://www.who.int/mediacentre/factsheets/fs241/ en/print.html

CHAPTER W O R K S H E E T MULTIPLE-CHOICE QUESTIONS 1. The primary goal of intervention in working with abused women is to: a. Set up an appointment with a mental health counselor for the victim b. Convince them to set up a safety plan to use when they leave c. Help them to develop courage and financial support to leave the abuser d. Empower them and improve their self-esteem to regain control of their lives 2. The first phase of the abuse cycle is characterized by: a. The woman provoking the abuser to bring about battering b. Tension building and verbal or minor battery c. A honeymoon period that lulls the victim into forgetting d. An acute episode of physical battering 3. Women recovering from abusive relationships need to learn ways to improve their: a. Educational level by getting a college degree b. Earning power so they can move to a better neighborhood c. Self-esteem and communication skills to increase assertiveness d. Relationship skills so they will be better prepared to deal with their partners 4. Which of the following statements might empower abuse victims to take action? a. “You deserve better than this.” b. “Your children deserve to grow up in a two-parent family.” c. “Try to figure out what you do to trigger his abuse and stop it.” d. “Give your partner more time to come to his senses about this.”

appointments. On occasion she has worn sunglasses to cover bruises around her eyes. As a nurse you sense there is something else bothering her, but she doesn’t seem to want to discuss it with you. She appears sad and the children cling to her. a. Outline your conversation when you broach the subject of abuse with Mrs. Boggs. b. What is your role as a nurse in caring for a family in which you suspect abuse is occurring? c. What ethical/legal considerations are important in planning care for this family? STUDY ACTIVITIES 1. Visit the BellaOnline web site for victims of violence. Discuss what you discovered on this site and your reactions to it. 2. Research the statistics about violence against women in your state. Are law enforcement and community interventions reducing the incidence of sexual assault and intimate partner violence? 3. Attend a dorm orientation at a local college to hear about measures in place to protect women’s safety on campus. Find out the number of sexual assaults reported and what strategies the college uses to reduce this number. 4. Volunteer to spend a weekend evening at the local sheriff’s department 911 hotline desk to observe the number and nature of calls received reporting domestic violence. Interview the dispatch operator about the frequency and trends of these calls. 5. Identify three community resources that could be useful to a victim of violence. Identify their sources of funding and the services they provide.

CRITICAL THINKING EXERCISE 1. Mrs. Boggs has three children under the age of 5 and is 6 months pregnant with her fourth child. She has made repeated unscheduled visits to your clinic with vague somatic complaints regarding the children as well as herself, but has missed several scheduled prenatal

303

unit three

Pregnancy

10 KEY TERMS allele blastocyst embryonic stage fertilization fetal stage genes genetic counseling genetics genome genomics genotype heterozygous homozygous karyotype mosaicism monosomies morula mutation phenotype placenta preembryonic stage teratogen trisomies trophoblast umbilical cord zona pellucida zygote

Fetal Development and Genetics Learning Objectives Upon completion of the chapter, you will be able to: 1. Define the key terms used in this chapter. 2. Characterize the process of fertilization, implantation, and cell differentiation. 3. Examine the functions of the placenta, umbilical cord, and amniotic fluid. 4. Outline normal fetal development from conception through birth. 5. Compare the various inheritance patterns, including nontraditional patterns of inheritance. 6. Analyze examples of ethical and legal issues surrounding genetic testing. 7. Research the role of the nurse in genetic counseling and genetic-related activities.

Robert and Kate Shafer have just received the good news that Kate’s pregnancy test is positive. It had been a long and anxious 3 years of trying to start a family. Although both are elated about the prospect of becoming parents, they are concerned about the possibility of a genetic problem because Kate is 38 years old. What might be their first step in looking into their genetic concern? As a nurse, what might raise concerns for you?

WOW

Words of Wisdom

Being a nurse without awe is like food without spice. Nurses only have to witness the miracle of life to find their lost awe.

308   U N I T 3  Pregnancy

Human reproduction is one of the most intimate spheres of an individual’s life. For conception to occur, a healthy ovum from the woman is released from the ovary, passes into an open fallopian tube, and starts its journey downward. Sperm from the male is deposited into the vagina and swims approximately 7 inches to meet the ovum at the outermost portion of the fallopian tube, the area where fertilization takes place (Gilbert, 2011). When one spermatozoon penetrates the ovum’s thick outer membrane, pregnancy begins. All this activity takes place within a 5-hour time span. Nurses caring for the childbearing family need to have a basic understanding of conception and prenatal development so they can identify problems or variations and can initiate appropriate interventions should any problems occur. This chapter presents an overview of fetal development, beginning with conception. It also discusses hereditary influences on fetal development and the nurse’s role in genetic counseling.

FETAL DEVELOPMENT Fetal development during pregnancy is measured in number of weeks after fertilization. The duration of pregnancy is about 40 weeks from the time of fertilization. This equates to 9 calendar months or approximately 266 to 280 calendar days. The three stages of fetal development during pregnancy are: 1. Preembryonic stage: fertilization through the sec­ ond week 2. Embryonic stage: end of the second week through the eighth week 3. Fetal stage: end of the eighth week until birth Fetal circulation is a significant aspect of fetal development that spans all three stages.

Preembryonic Stage The preembryonic stage begins with fertilization, also called conception. Fertilization is the union of ovum and sperm, which is the starting point of pregnancy. Fertilization typically occurs around 2 weeks after the last normal menstrual period in a 28-day cycle (D’Amico, 2012). Fertilization requires a timely interaction between the release of the mature ovum at ovulation and the ejaculation of enough healthy, mobile sperm to survive the hostile vaginal environment through which they must travel to meet the ovum. All things considered, the act of conception is difficult at best. To say merely that it occurs when the sperm unites with the ovum is overly simple because this union requires an intricate interplay of hormonal preparation and overcoming an overwhelming number of natural barriers. A human being is truly an amazing outcome of this elaborate process.

Prior to fertilization, the ovum and the spermatozoon undergo the process of meiosis. The primary oocyte completes its first meiotic division before ovulation. The secondary oocyte begins its second meiotic division just before ovulation. Primary and secondary spermatocytes undergo meiotic division while still in the testes (Fig. 10.1). Although more than 200 million sperm/mL are contained in the ejaculated semen, only one is able to enter the ovum to fertilize it. All others are blocked by the clear protein layer called the zona pellucida. The zona pellucida disappears in about 5 days. Once the sperm reaches the plasma membrane, the ovum resumes meiosis and forms a nucleus with half the number of chromosomes (23). When the nucleus from the ovum and the nucleus of the sperm make contact, they lose their respective nuclear membranes and combine their maternal and paternal chromosomes. Because each nucleus contains a haploid number of chromosomes (23), this union restores the diploid number (46). The resulting zygote begins the process of a new life. The genetic information from both ovum and sperm establishes the unique physical characteristics of the individual. Sex determination is also determined at fertilization and depends on whether the ovum is fertilized by a Y-bearing sperm or an ­X-bearing sperm. An XX zygote will become a female and an XY zygote will become a male (Fig. 10.2). Fertilization takes place in the outer third of the ampulla of the fallopian tube. When the ovum is fertilized by the sperm (now called a zygote), a great deal of activity immediately takes place. Mitosis, or cleavage, occurs as the zygote is slowly transported into the uterine cavity by tubal muscular movements (Fig. 10.3). After a series of four cleavages, the 16 cells appear as a solid ball of cells, or morula, meaning “little mulberry.” The morula reaches the uterine cavity about 72 hours after fertilization. As fluid, which provides nutrients, from the uterine cavity enters the morula, the blastocyst is formed (­ Blackburn, 2013). With additional cell division, the morula divides into specialized cells that will later form fetal structures. Within the morula, an off-center, fluid-filled space ­appears, transforming it into a hollow ball of cells called a blastocyst (Fig. 10.4). The inner surface of the blastocyst will form the embryo and amnion. The outer layer of cells surrounding the blastocyst cavity is called a trophoblast. Eventually, the trophoblast develops into one of the embryonic membranes, the chorion, and helps to form the placenta. At this time, the developing blastocyst needs more food and oxygen to keep growing. The trophoblast attaches itself to the surface of the endometrium for further nourishment. Normally, implantation occurs in the upper uterus (fundus), where a rich blood supply is available.



C h a p t e r 1 0   Fetal Development and Genetics    309

Oogonium Spermatogonium 46 Primary oocyte 46 Primary spermatocyte 23

23 First polar body

23 23 Secondary spermatocytes

23

FIGURE 10.1 The formation of gametes by the ­process of meiosis is known as gametogenesis. (A) Spermatogenesis. One spermatogonium gives rise to four spermatozoa. (B) Oogenesis. From each oogonium, one mature ovum and three abortive cells are produced. The chromosomes are reduced to onehalf the number characteristic for the general body cells of the species. In humans, the number in the body cells is 46, and that in the mature spermatozoon and secondary oocyte is 23.

A

23

23

23

B

Spermatids Head Middle piece

23 23 Polar bodies

Secondary oocyte

23

23 Mature ovum

Tail

Spermatozoa

46 Mitosis

22Y

22X Sperm

22X

Replication of genetic material

22X Egg (ovum)

Fertilized egg 44XY Male

Mitosis

44XX Female

FIGURE 10.2 Inheritance of gender. Each ovum contains 22 autosomes and an X chromosome. Each spermatozoon (sperm) contains 22 autosomes and either an X chromosome or a Y chromosome. The gender of the zygote is determined at the time of fertilization by the combination of the sex chromosomes of the sperm (either X or Y) and the ovum (X).

46

46

FIGURE 10.3 Mitosis of the stoma cells.

46

46

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A

B

FIGURE 10.4 (A) Fertilized human egg (zygote) having reached the blastocyst stage. Zygote contains 20 to 30 eggs and a fluid-filled blastocele is beginning to form. (B) Implantation. Stylized image showing a frontal view of a uterus with a blastocyst about to implant into endometrium of the uterus. Images from LifeART image copyright (c) 2011 Lippincott Williams & Wilkins. All rights reserved.

This area also contains strong muscular fibers, which clamp down on blood vessels after the placenta separates from the inner wall of the uterus. Additionally, the lining is thickest here so the placenta cannot attach so strongly that it remains attached after birth (Alvero &

Schlaff, 2012). Figure 10.5 shows the process of fertilization and implantation. Concurrent with the development of the trophoblast and implantation, further differentiation of the inner cell mass occurs. Some of the cells become the embryo itself, 4 cell stage (48 hours)

2 cell stage (36 hours) Fertilization

Morula Blastocyst Zona pellucida

Inner cell mass

Corona radiata

Blastocele

Ovum (enlarged for greater clarity) Sperm Fallopian tube

Trophoblast

Corpus Ovum Corpus albicans luteum

FIGURE 10.5 Fertilization and tubal transport of the zygote. From fertilization to implantation, the zygote travels through the fallopian tube, experiencing rapid mitotic division (cleavage). During the journey toward the uterus the zygote evolves through several stages, including morula and blastocyst.

Artery and vein

Implantation (7–8 days) Embryonic disc Endometrium of uterus

Primary follicles

Ovulation Ovary

Maturing follicles



C h a p t e r 1 0   Fetal Development and Genetics    311 BOX 10.1

SUMMARY OF PREEMBRYONIC DEVELOPMENT • Fertilization takes place in ampulla of the fallopian tube. • Union of sperm and ovum forms a zygote (46 chromosomes). • Cleavage cell division continues to form a morula (mass of 16 cells). • The inner cell mass is called blastocyst, which forms the embryo and amnion. • The outer cell mass is called trophoblast, which forms the placenta and chorion. • Implantation occurs 7 to 10 days after conception in the endometrium.

and others give rise to the membranes that surround and protect it. The three embryonic layers of cells formed are: 1. Ectoderm—forms the central nervous system, special senses, skin, and glands 2. Mesoderm—forms the skeletal, urinary, circulatory, and reproductive organs 3. Endoderm—forms the respiratory system, liver, pancreas, and digestive system These three layers are formed at the same time as the embryonic membranes, and all tissues, organs, and organ systems develop from these three primary germ cell layers (D’Amico, 2012). Box 10.1 summarizes preembryonic development. Despite the intense and dramatic activities going on internally to create a human life, many women are unaware that pregnancy has begun. Several weeks will pass before even one of the presumptive signs of pregnancy— missing the first menstrual period—will take place.

Embryonic Stage The embryonic stage of development begins at day 15 after conception and continues through week 8. Basic structures of all major body organs and the main external features are completed during this time period. Table 10.1 and Figure 10.6 summarize embryonic development. The embryonic membranes (Fig.  10.7) begin to form around the time of implantation. The chorion consists of trophoblast cells and a mesodermal lining. It has fingerlike projections called chorionic villi on its surface. The amnion originates from the ectoderm germ layer during the early stages of embryonic development. It is a thin protective membrane that contains amniotic fluid. As the embryo grows, the amnion expands until it touches the chorion. These two fetal membranes

form the fluid-filled amniotic sac, or bag of waters, that protects the floating embryo (Creatsas, Chrousos, & ­Mastorakos, 2010). Amniotic fluid surrounds the embryo and increases in volume as the pregnancy progresses, reaching approximately 1 L at term. Amniotic fluid is derived from two sources: fluid transported from the maternal blood across the amnion and fetal urine. Its volume changes constantly as the fetus swallows and voids. Sufficient amounts of amniotic fluid help maintain a constant body temperature for the fetus, permit symmetric growth and development, cushion the fetus from trauma, allow the umbilical cord to be relatively free from compression, and promote fetal movement to enhance musculoskeletal development. Amniotic fluid is composed of 98% water and 2% organic matter. It is slightly alkaline and contains albumin, urea, bile pigments, renin, glucose, hormones, uric acid, creatinine, bilirubin, lecithin, sphingomyelin, epithelial cells, vernix, and fine hair called lanugo. The composition of amniotic fluid changes with gestation (Blackburn, 2013). The volume of amniotic fluid is important in determining fetal well-being. It gradually fluctuates throughout the pregnancy. Alterations in amniotic fluid volume can be associated with problems in the fetus. Too little amniotic fluid (2,000 mL at term), termed hydramnios, is associated with maternal diabetes, neural tube defects, chromosomal deviations, and malformations of the central nervous system and/ or gastrointestinal tract that prevent normal swallowing of amniotic fluid by the fetus. Hydramnios may threaten premature rupture of membranes due to uterine overdistention (Gilbert, 2011). While the placenta is developing (end of the second week), the umbilical cord is also formed from the amnion. It is the lifeline from the mother to the growing embryo. It contains one large vein and two small arteries. Wharton’s jelly (a specialized connective tissue) surrounds these three blood vessels in the umbilical cord to prevent compression, which would cut off fetal blood and nutrient supply. The cord reaches its maximum length by 30 weeks of gestation. Its length is determined by genetics and intrauterine space and fetal activity, which places tension on the cord. At term, the average umbilical cord is 22 inches long and about 1 inch wide (Polin, Fox, & Abman, 2011). The precursor cells of the placenta—the ­trophoblasts—first appear 4 days after fertilization as the outer layer of cells of the blastocyst. These early blastocyst trophoblasts differentiate into all the cells that form the placenta. When fully developed, the placenta serves as the interface between the mother and the developing fetus. As early as 3 days after conception, the trophoblasts make human chorionic gonadotropin

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TABLE 10.1

EMBRYONIC AND FETAL DEVELOPMENT

WEEK 3 Beginning development of brain, spinal cord, and heart Beginning development of the gastrointestinal tract Neural tube forms, which later becomes the spinal cord Leg and arm buds appear and grow out from body WEEK 4

Digestive system shows activity Head comprises nearly half the fetus size Face and neck are well formed Urogenital tract completes development Red blood cells are produced in the liver Urine begins to be produced and excreted Fetal gender can be determined by week 12 Limbs are long and thin; digits are well formed

Brain differentiates Limb buds grow and develop more Stomach, the pancreas, and liver begin to form

12 weeks

4 weeks

WEEK 5 Heart now beats at a regular rhythm Beginning structures of eyes and ears Some cranial nerves are visible Muscles innervated WEEK 6 Beginning formation of lungs Fetal circulation established Liver produces RBCs Further development of the brain Primitive skeleton forms Central nervous system forms Brain waves detectable

WEEKS 13–16 A fine hair develops on the head called lanugo Fetal skin is almost transparent Bones become harder Head still dominant Fetus makes active movement Sucking motions are made with the mouth Amniotic fluid is swallowed Fingernails and toenails present Weight quadruples Fetal movement (also know as quickening) detected by mother

WEEK 7 Straightening of trunk Nipples and hair follicles form Elbows and toes visible Arms and legs move Diaphragm formed Fetal heartbeat can be heard Mouth with lips and early tooth buds WEEK 8 Rotation of intestines Facial features continue to develop Heart development complete Resembles a human being (Mattson & Smith, 2011)

16 weeks

WEEKS 17–20 Rapid brain growth occurs Fetal heart tones can be heard with stethoscope Kidneys continue to secret urine into amniotic fluid Vernix caseosa, a white greasy film, covers the fetus Eyebrows and head hair appear Sebaceous glands appear Brown fat deposited to help maintain temperature Nails are present on both fingers and toes Muscles are well developed

8 weeks

WEEKS 9–12 Sexual differentiation continues Buds for all 20 temporary teeth laid down

20 weeks



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TABLE 10.1

EMBRYONIC AND FETAL DEVELOPMENT (continued)

WEEKS 21–24 Eyebrows and eyelashes are well formed Fetus has a hand grasp and startle reflex Alveoli forming in lungs Body is lean but fairly well proportioned Skin is translucent and red Lungs begin to produce surfactant

Rhythmic breathing movements occur Lungs are not fully mature Fetus stores iron, calcium, and phosphorus

32 weeks

WEEKS 33–38 25 weeks

WEEKS 25–28 Fetus reaches a length of 15 inches Rapid brain development Eyelids open and close Nervous system controls some functions Fingerprints are set Blood formation shifts from spleen to bone marrow Fetus usually assumes head-down position

28 weeks

Testes are in scrotum of male fetus Lanugo begins to disappear Increase in body fat Fingernails reach the end of fingertips Small breast buds are present on both sexes Mother supplies fetus with antibodies against disease Fetus is considered full term at 38 weeks Fetus fills uterus (Blackburn, 2013)

37 weeks

WEEKS 29–32 Rapid increase in the amount of body fat Increased central nervous system control over body functions

(hCG), a hormone that ensures that the endometrium will be receptive to the implanting embryo. During the next few weeks the placenta begins to make hormones that control the basic physiology of the mother in such a way that the fetus is supplied with the nutrients and oxygen needed for growth. The placenta also protects the fetus from immune attack by the mother, removes waste products from the fetus, induces the mother to bring more food to the placenta and, near the time of delivery, produces hormones that ready fetal organs for life outside the uterus. Placenta function depends on the maternal blood pressure supplying circulation. If there is

an interference with blood flow to the placenta, it cannot carry out its functions to the embryo or fetus (Mattson & Smith, 2011). At no time during pregnancy does the mother’s blood mix with fetal blood because there is no direct contact between their bloods; layers of fetal tissue always separate the maternal blood and the fetal blood. These fetal tissues are called the placental barrier. Materials can be interchanged only through diffusion. The maternal uterine arteries deliver the nutrients to the placenta, which in turn provides nutrients to the developing f­etus; the mother’s uterine veins carry fetal waste products  away.

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A

C

B

FIGURE 10.6 Embryonic development. (A) 4-week embryo. (B) 5-week embryo. (C) 6-week embryo.

The structure of the placenta is usually completed by week 12. The placenta is not only a transfer organ but a factory as well. It produces several hormones necessary for normal pregnancy: • hCG—preserves the corpus luteum and its progesterone production so that the endometrial lining of the Uterine fundus

uterus is maintained; this is the basis for pregnancy tests • Human placental lactogen (hPL)—modulates fetal and maternal metabolism, participates in the development of maternal breasts for lactation, and decreases maternal insulin sensitivity to increase its availability for fetal nutrition

Amnion

Chorion

Umbilical cord

AC

Placenta

C H

A

Cervix

B

FIGURE 10.7 (A) The embryo is floating in amniotic fluid, surrounded by the protective fetal membranes (amnion and chorion). (B) Longitudinal sonogram of a pregnant uterus at 11 weeks showing the intrauterine gestational sac (black arrowheads) and the amniotic cavity (AC) filled with amniotic fluid; the fetus is seen in longitudinal section with the head (H) and coccyx (C) well displayed. The myometrium (MY) of the uterus can be identified. (Figure B is courtesy of L Scoutt.)

MY



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• Estrogen (estriol)—causes enlargement of a woman’s breasts, uterus, and external genitalia; stimulates myometrial contractility • Progesterone (progestin)—maintains the endometrium, decreases the contractility of the uterus, stimulates maternal metabolism and breast development, provides nourishment for the early conceptus • Relaxin—acts synergistically with progesterone to maintain pregnancy, causes relaxation of the pelvic ligaments, softens the cervix in preparation for birth (Alvero & Schlaff, 2012). The placenta acts as a pass-through between the mother and fetus, not a barrier. Almost everything the mother ingests (food, alcohol, drugs) passes through to the developing conceptus. This is why it is so important to advise pregnant women not to use drugs, alcohol, and tobacco, because they can be harmful to the conceptus. During the embryonic stage, the conceptus grows rapidly as all organs and structures are forming. During this critical period of differentiation the growing embryo is most susceptible to damage from external sources, including teratogens (substances that cause birth defects, such as alcohol and drugs), infections (such as rubella or cytomegalovirus), radiation, and nutritional deficiencies.

Fetal Stage The average pregnancy lasts 280 days from the first day of the last menstrual period. The fetal stage is the time from the end of the eighth week until birth. It is the longest period of prenatal development. During this stage, the conceptus is mature enough to be called a fetus. Although all major systems are present in their basic form, dramatic growth and refinement of all organ systems take place during the fetal period (see Table 10.1). ­Figure 10.8 depicts a 12- to 15-week-old fetus.

Fetal Circulation The circulation through the fetus during uterine life differs from that of a child or an adult. In the extrauterine world, oxygenation occurs in the lungs and oxygenated

FIGURE 10.8 Fetal development: 12- to 15-week fetus.

blood returns via the pulmonary veins to the left side of the heart to be ejected by the left ventricle into the systemic circulation. In contrast, fetal circulation oxygenation occurs in the placenta, and the fetal lungs are nonfunctional as far as the transfer of oxygen and carbon dioxide is concerned. For oxygenated blood derived from the placenta to reach the fetus’s systemic circulation, it has to travel through a series of shunts to accomplish this. Thus, fetal circulation involves the circulation of blood from the placenta to and through the fetus, and back to the placenta. A properly functioning fetal circulation system is essential to sustain the fetus. Before it develops, nutrients and oxygen diffuse through the extraembryonic coelom and the yolk sac from the placenta. As the embryo grows, its nutrient needs increase and the amount of tissue easily reached by diffusion increases. Thus, the circulation must develop quickly and accurately (Blackburn, 2013). The circulatory system of the fetus functions much differently from that of a newborn. The most significant difference is that oxygen is received from the placenta during fetal life and via the lungs after birth. In addition, the fetal liver does not perform the metabolic functions that it will after birth because the mother’s body performs these functions. Three shunts also are present during fetal life: 1. Ductus venosus—connects the umbilical vein to the inferior vena cava 2. Ductus arteriosus—connects the main pulmonary artery to the aorta 3. Foramen ovale—anatomic opening between the right and left atrium

Take Note! Fetal circulation functions to carry highly oxygenated blood to vital areas (e.g., heart, brain) while first shunting it away from less important ones (e.g., lungs, liver). The placenta essentially takes over the functions of the lungs and liver during fetal life. As a result, large volumes of oxygenated blood are not needed. The oxygenated blood is carried from the placenta to the fetus via the umbilical vein. About half of this blood passes through the hepatic capillaries and the rest flows through the ductus venosus into the inferior vena cava. Blood from the vena cava is mostly deflected through the foramen ovale into the left atrium, then to the left ventricle, into the ascending aorta, and on to the head and upper body. This allows the fetal coronary circulation and the brain to receive the blood with the highest level of oxygenation. Deoxygenated blood from the superior vena cava flows into the right atrium, the right ventricle, and then the pulmonary artery. Because of high pulmonary vascular resistance, only a small percentage (5% to 10%) of

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the blood in the pulmonary artery flows to the lungs; the majority is shunted through the patent ductus arteriosus and then to the descending aorta (Blackburn, 2013). The fetal lungs are essentially nonfunctional because they are filled with fluid, making them resistant to incoming blood flow. They receive only enough blood for proper nourishment. Finally, two umbilical arteries carry the unoxygenated blood from the descending aorta back to the placenta. At birth, a dramatic change in the fetal circulatory pattern occurs. The foramen ovale, ductus arteriosus, ductus venosus, and umbilical vessels are no longer needed. With the newborn’s first breath, the lungs inflate, which leads to an increase in blood flow to the lungs from the right ventricle. This increase raises the pressure in the left atrium, causing a one-way flap on the left side of the foramen ovale, called the septum primum, to press against the opening, creating a functional separation between the two atria. Blood flow to the lungs increases because blood entering the right atrium can no longer bypass the right ventricle. As a result, the right ventricle pumps blood into the pulmonary artery and on to the lungs. Typically the foramen ovale is functionally closed within 1 to 2 hours after birth. It is physiologically closed by 1  month with deposits of fibrin to seal the shunt. Permanent closure occurs by the sixth month of life. The ductus venosus, which links the inferior vena cava with the umbilical vein, usually closes with the clamping of the umbilical cord and inhibition of blood flow through the umbilical vein. This fetal structure closes by the end of the first week. The ductus arteriosus constricts partly in response to the higher arterial oxygen levels that occur after the first few breaths. This closure prevents blood from the aorta from entering the pulmonary artery. Functional closure of the ductus arteriosus in a term infant usually occurs within the first 72 hours after birth. Permanent closure occurs at 3 to 4 weeks of age (Blackburn, 2013). Frequently a functional or innocent murmur is auscultated by the nursery nurse when there are delayed fetal shunt closures, but they usually are not associated with a heart lesion ( Jarvis, 2012). All of these changes at birth leave the newborn with the typical adult pattern of circulation. Figure 10.9 shows fetal circulation.

GENETICS Genetics is the study of heredity and its variation (Beery & Workman, 2012). Genomics, a relatively new science, is the study of all genes and includes interactions among genes as well as interactions between genes and the environment. Genomics plays a role in complex conditions such as heart disease and diabetes. Another emerging area of research is that of pharmacogenomics,

the study of genetic and genomic influences on pharmacodynamics and pharmacotherapeutics (Lewis, 2011). According to the Centers for Disease Control and Prevention (CDC), birth defects occur in about 3% of all infants born in the United States, or 1 in every 33 infants (CDC, 2011). Traditionally, genetics has been associated with making decisions about childbearing and caring for children with genetic disorders. Recently, genetic and technologic advances are expanding our understanding of how genetic changes affect human diseases such as diabetes, cancer, Alzheimer’s disease, and other multifactorial diseases that are prevalent in adults (Eisenstein, 2011). Newborn screening is perhaps the most widely used application of genetics in perinatal and neonatal care. Our ability to diagnose genetic conditions is more advanced than our ability to cure or treat the disorders. However, accurate diagnosis has led to improved treatment and outcomes for those affected with these disorders.

Take Note! Genetic science has the potential to revolutionize health care with regard to national screening programs, predisposition testing, detection of genetic disorders, and pharmacogenetics. Genetics has been a part of perinatal care for decades. Ultrasounds and maternal serum screening have become routine elements of prenatal care. Preconception carrier screening for conditions such as Tay-Sachs disease has been in place among high-risk populations such as Ashkenazi Jews. Amniocentesis and chorionic villus sampling are diagnostic tests that may confirm a genetic anomaly in a developing fetus. Fetal nuchal translucency, as seen on ultrasound, is suggestive of the presence of trisomy 21 or Down syndrome (Lewis, 2011). Today, nurses are required to have basic skills and knowledge in genetics, genetic testing, and genetic counseling so they can assume new roles and provide information and support to women, children, and families. Roles for maternity nurses in genetic health care have expanded significantly as genetics education and counseling has become standard of care. Today, nurses may provide preconception counseling for women at risk for the transmission of a genetic disorder. In addition, they may provide prenatal care for women with genetically linked disorders that require specialized care or participate in screening infants for birth defects and genetic disorders (Beery & Workman, 2011). Nurses at all levels should be participating in risk assessment for genetic conditions and disorders, explaining genetic risk and genetic testing, and supporting informed health ­decisions and opportunities for early intervention ­ (American Nurses Association [ANA], 2009).



C h a p t e r 1 0   Fetal Development and Genetics    317 To head

To arm Aorta

Superior vena cava

Ductus arteriosus

Right lung

Left lung

Right atrium

Left atrium

Foramen ovale Inferior vena cava

Aorta Liver Ductus venosus

Portal vein

Umbilicus

Umbilical vein

From placenta To leg To placenta

Umbilical arteries

FIGURE 10.9 Fetal circulation. Arrows indicate the path of blood. The umbilical vein carries oxygen-rich blood from the placenta to the liver and through the ductus venosus. From there it is carried to the inferior vena cava to the right atrium of the heart. Some of the blood is shunted through the foramen ovale to the left side of the heart, where it is routed to the brain and upper extremities. The rest of the blood travels down to the right ventricle and through the pulmonary artery. A small portion of the blood travels to the nonfunctioning lungs, while the remaining blood is shunted through the ductus arteriosus into the aorta to supply the rest of the body.

It is very clear that genomics will have a profound effect on health and illness at all levels. In the future, as the era of personalized health care moves forward, nurses will be responsible for ensuring that our practice includes the scientific principles, ethical standards, and professional accountability of genetics and genomics practice.

Nurses are increasingly incorporating genetics into their practice as they gain the knowledge and skills necessary to do so. The strength of the nursing voice in genetics and genomic research will be the link to the bedside and the commitment to ensure that new knowledge is translated into evidence-based client care (Lewis, 2011).

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Advances in Genetics Recent advances in genetic knowledge and technology have affected all areas of health. These advances have increased the number of health interventions that can be undertaken with regard to genetic disorders. For example, genetic diagnosis is now possible before conception and very early in pregnancy (see Evidence-Based Practice 10.1). Genetic testing can identify presymptomatic conditions in children and adults, and provide carrier screening, prenatal diagnostic testing, newborn screening, confirmation of a diagnosis, forensic and

EVIDENCE-BASED PRACTICE 10.1

identity testing, and preimplantation genetic diagnosis (U.S. ­Department of Energy Genome Programs, 2010). Over 1,000 genetic tests are available for diseases such as Duchenne muscular dystrophy/Becker muscular dystrophy, cystic fibrosis, and sickle cell disease (U.S. Department of Energy Genome Programs, 2010). Gene therapy can be used to replace or repair defective or missing genes with normal ones. Although it is a promising treatment option for many inherited and incurable diseases, it currently remains an experimental treatment option (U.S. Department of Energy Genome Programs, 2011a). The FDA has not approved the sale of any gene

PREIMPLANTATION GENETIC SCREENING AND PROMOTING PREGNANCY WITH ASSISTED REPRODUCTIVE TECHNOLOGIES

STUDY Assisted reproductive technologies such as in vitro fertilization (IVF) and intracytoplasmic sperm injection (ICSI) involve the transfer of an embryo to the mother to achieve pregnancy. The physician selects the embryos for transfer based on specific criteria related to their structure and form. These “good-quality” embryos are then implanted in the mother in the hopes of achieving a pregnancy. Unfortunately, many women do not experience a pregnancy. The reasons for these failures are not known. One belief is that the embryos being transferred, although they meet the criteria for structure and form, may have an abnormal number of chromosomes, which affects implantation and the development of a pregnancy. Preimplantation genetic screening (PGS) is a tool being used to identify embryos of good quality with the normal number of chromosomes. Based on the screening, only these embryos are implanted; in theory, this would increase the rate of pregnancy. However, there are questions as to how effective PGS is in improving the rates of pregnancy and live birth. Two independent authors used predetermined quality criteria to collect and analyze data from numerous databases, registers, and reference lists of articles. The researchers also gathered additional data from other authors as necessary. The researchers selected all relevant randomized controlled trials dealing with IVF or ICSI with and without PGS. The researchers measured the outcome based primarily on the live birth rate. Nine trials met the inclusion criteria. Live birth rate per woman was significantly lower after IVF/ ICSI with PGS compared to IVF/ICSI without PGS in women of advanced maternal age and in women with repeated IVF failure (OR 0.59; 95% CI 0.44 to 0.81 and OR 0.41, 95% CI 0.20 to 0.88, respectively). In good-prognosis clients a similar trend was seen, albeit not significant (OR 0.50, 95% CI 0.20 to 1.26, random effects model).

Findings Preimplantation genetic screening, as currently performed, significantly decreases live birth rates in women of advanced maternal age and those with repeated IVF failure. Trials in which PGS was offered to women with a good prognosis suggested similar outcomes. PGS technique development is still ongoing in an effort to increase its efficacy. This involves biopsy at other stages of development (polar body or trophectoderm biopsy) and other methods of analysis (comparative genome hybridization [CGH] or array-based technologies) than used by the trials included in this review. These new developments should be properly evaluated before their routine clinical application. Until such trials have been performed, PGS should not be offered as routine client care in any form.

Nursing Implications Although the study failed to support the effectiveness of PGS, nurses need to be aware of the emerging technology and techniques associated with genetics so that they can provide women and their families with the most appropriate information about available options and therapies. Nurses can incorporate information from this study in their teaching, anticipatory guidance, and counseling activities related to options so that couple can make the best-informed decision possible. Twisk, M., Mastenbroek, S., van Wely, M., Heineman, M. J., Van der Veen, F., & Repping, S. (2011). Preimplantation genetic screening for abnormal number of chromosomes (aneuploidies) in in vitro fertilization or intracytoplasmic sperm injection. Cochrane Database of Systematic Reviews, Issue 2. Art. No.: CD005291.DOI:10.1002/14651858.CD005291. pub2.



therapy and current clinical trials have yielded minimal success (U.S. Department of Energy Genome Programs, 2011a). The Human Genome Project (HGP) and continued research by the National Human Genome Research Institute has helped foster much of this progress. The genome of an organism is its entire hereditary information encoded in the DNA. The HGP, in an international effort to produce a comprehensive sequence of the human genome, was coordinated by the U.S. Department of Energy and the National Institutes of Health. It began in October 1990 and was completed in May 2003. Its goals included: • Identify all of the approximately 20,000–25,000 genes in human DNA. • Determine the sequences of the 3  billion chemical base pairs that make up human DNA. • Store this information in databases to make it accessible for further study. • Improve tools for data analysis. • Transfer related technologies to the private sector. • Address the ethical, legal, and social implications of this discovery (U.S. Department of Energy Genome Programs, 2011b). The HGP has led to the discovery of the genetic basis for hundreds of disorders and has advanced our understanding of basic genetic processes at the molecular level. A link to additional information about HGP is available on . One goal of the HGP was to translate the findings into new and more effective strategies for the prevention, diagnosis, and treatment of genetic diseases and disorders. Current and potential applications for the HGP to health care include rapid and more specific diagnosis of disease, with hundreds of genetic tests available in research or clinical practice; earlier detection of genetic predisposition to disease; less emphasis on treating the symptoms of a disease and more emphasis on looking at the fundamental causes of the disease; new classes of drugs; avoiding environmental conditions that may trigger disease; and repair or replacement of defective genes through gene therapy. This new genetic knowledge and technology, along with the commercialization of this knowledge, will change both professional and parental understanding of genetic disorders. The potential benefits of these discoveries are vast, but so is the potential for misuse. These advances challenge all health care professionals to consider the many ethical, legal, and social ramifications of genetics in human lives. In the near future, risk profiling based on an individual’s unique genetic makeup will be used to tailor prevention, treatment, and ongoing management of health conditions. This profiling will raise issues associated with privacy and confidentiality related to

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workplace discrimination and access to health insurance. Issues of autonomy are equally problematic as society considers how to address the injustices that will inevitably surface when disease risk can be determined years in advance of its occurrence. Nurses will play an important role in developing policies and providing direction and support in this arena, and to do so they will need a basic understanding of genetics, including inheritance and inheritance patterns. Visit for links to websites sharing additional information on the ethical, social, and legal issues surrounding human genetic research and advances.

Inheritance The nucleus within the cell is the controlling factor in all cellular activities because it contains chromosomes, long continuous strands of deoxyribonucleic acid (DNA) that carry genetic information. Each chromosome is made up of genes. Genes are individual units of heredity of all traits and are organized into long segments of DNA that occupy a specific location on a chromosome and determine a particular characteristic in an organism. DNA stores genetic information and encodes the instructions for synthesizing specific proteins needed to maintain life. DNA is double-stranded and takes the form of a double helix. The side pieces of the double helix are made up of a sugar, deoxyribose, and a phosphate, occurring in alternating groups. The cross connections or rungs of the ladder are attached to the sides and are made up of four nitrogenous bases: adenine, cytosine, thymine, and guanine. The sequence of the base pairs as they form each rung of the ladder is referred to as the genetic code (Fig. 10.10) (Zhang & Yu, 2011). Each gene has a segment of DNA with a specific set of instructions for making proteins needed by body cells for proper functioning. Genes control the types of proteins made and the rate at which they are produced (Beery & Workman, 2012). Any change in gene structure or location leads to a mutation, which may alter the type and amount of protein produced (Fig.  10.11). Genes never act in isolation; they always interact with other genes and the environment. They are arranged in a specific linear formation along a chromosome. The genotype, the specific genetic makeup of an individual, usually in the form of DNA, is the internally coded inheritable information. It refers to the particular allele, which is one of two or more alternative versions of gene at a given position or locus on a chromosome that imparts the same characteristic of that gene. For instance, each human has a gene that controls height, but there are variations of these genes, which are alleles, in accordance with the specific height for which the gene codes. A gene that controls eye color may have an allele that can produce blue eyes or an allele that produces brown eyes. The genotype, together with

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Cell

Nucleus

Chromosomes

DNA molecule Gene

Chemical bases

FIGURE 10.10 DNA is made up of four chemical bases. Tightly coiled strands of DNA are packaged in units called chromosomes, housed in the cell’s nucleus. Working subunits of DNA are known as genes. (From the National Institute of Health and National Cancer Institute. [1995]. Understanding gene testing [NIH Pub. No. 96-3905]. ­Washington, DC: U.S. Department of Human Services.)

Nucleus

environmental variation that influences the individual, determines the phenotype, or the observed, outward characteristics of an individual. A human inherits two genes, one from each parent. Therefore, one allele comes from the mother and one from the father. These alleles may be the same for the characteristic (homozygous) or different (heterozygous). For example, WW stands for homozygous dominant; ww stands for homozygous recessive. Heterozygous would be indicated as Ww. If the two alleles differ, such as Ww, the dominant one will usually be expressed in the phenotype of the individual. Human beings typically have 46 chromosomes. This includes 22 pairs of non-sex chromosomes or autosomes and 1 pair of sex chromosomes (two X chromosomes in females, and an X chromosome and a Y chromosome in males). Offspring receive one chromosome of each of the 23 pairs from each parent. Regulation and expression of the thousands of human genes is very complex and is the result of many intricate interactions within each cell. Alterations in gene structure, function, transcription, translation, and protein synthesis can influence an individual’s health (Battista, Blancquaert, Laberge, van Schendel, & Leduc, 2012). Gene mutations are a permanent change in the sequence of DNA. Some mutations have no significant effect, whereas others can have a tremendous impact on the health of the individual. Several genetic disorders can result from these mutations, such as cystic fibrosis, sickle cell disease, phenylketonuria, or hemophilia. The pictorial analysis of the number, form, and size of an individual’s chromosomes is termed the karyotype. This analysis commonly uses white blood cells and fetal cells in amniotic fluid. The chromosomes are numbered from the largest to the smallest, 1 to 22, and the sex chromosomes are designated by the letter X or  Y.

DNA Cell membrane

DNA bases

Chain of amino acids

Gene mRNA Altered protein Ribosome

FIGURE 10.11 When a gene contains a mutation, the protein encoded by that gene will be abnormal. Some protein changes are insignificant, while others are disabling. (From the National Institutes of Health and National Cancer Institute. [1995]. Understanding gene testing [NIH Pub. No. 96-3905]. Washington, DC: U.S. Department of Human Services.)



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A

B

FIGURE 10.12 Karyotype pattern. (A) Normal female karyotype. (B) Normal male karyotype.

A female karyotype is designated as 46,XX and a male karyotype is designated as 46,XY. Figure 10.12 illustrates an example of a karyotyping pattern.

Patterns of Inheritance for Genetic Disorders Patterns of inheritance demonstrate how genetic abnormalities can be passed on to offspring. Although diagnosis of a genetic disorder is usually based on clinical signs and symptoms or on laboratory confirmation of an altered gene associated with the disorder, accurate diagnosis can be aided by the recognition of the pattern of inheritance within a family. In addition, nurses must understand the patterns of inheritance so they can teach and counsel families about the risks of genetic disorders occurring in future pregnancies. Some genetic disorders occur in multiple family members, while others may occur in only a single family member. A genetic disorder is caused by completely or partially altered genetic material, whereas a familial disorder is more common in relatives of the affected individual but may be caused by environmental influences and not genetic alterations. For a more detailed discussion of specific types of genetic disorders, see Chapter 51.

Mendelian or Monogenic Laws of Inheritance Principles of inheritance of single-gene disorders are the same principles that govern the inheritance of other traits, such as eye and hair color. These are known as Mendel’s laws of inheritance, named for Gregor Mendel, an Austrian naturalist who conducted genetic research. These patterns occur because a single gene is defective and the disorders that result are referred to as monogenic or, sometimes, Mendelian disorders. If the defect occurs on the autosome, the genetic disorder is termed autosomal; if the defect is on the X chromosome, the genetic disorder is termed X-linked. The defect also can be classified as dominant or recessive. Monogenic disorders include autosomal dominant, autosomal recessive, X-linked dominant, and X-linked recessive patterns. AUTOSOMAL DOMINANT INHERITANCE DISORDERS Autosomal dominant inherited disorders occur when a single gene in the heterozygous state is capable of producing the phenotype. In other words, the a­ bnormal or mutant gene overshadows the normal gene and the person will demonstrate signs and symptoms of the disorder. The affected person generally has an affected parent.

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However, there are varying degrees of presentation among individuals in a family. For example, a parent with a mild form of the disorder could have a child with a more severe form (termed variable expression). In some autosomal dominant disorders there may be no history of an affected family member. This can be due to the child representing a new mutation or the result of incomplete or reduced penetrance, which means that a person with the genetic mutation does not develop phenotypic features of the disorder. Incomplete or reduced penetrance may result from a combination of genetic, environmental and lifestyle factors, age, and gender. Offspring of an affected parent will have a 50% chance of inheriting two normal genes (disorder free) and a 50% chance of inheriting one normal and one abnormal gene (and, thus, the disorder) (Fig. 10.13) (Conley, 2010; Scott & Lee, 2011). Females and males are equally affected by autosomal dominant disorders and an affected male can pass the disorder on to his son (Scott & Lee, 2011). This male-to-male transmission is important in distinguishing autosomal dominant inheritance from X-linked inheritance. Common types of genetic disorders that follow the autosomal dominant pattern of inheritance include neurofibromatosis (genetic disorders affecting the development and growth of neural cells and tissues), Huntington’s disease (a genetic disorder affecting the nervous system characterized by abnormal involuntary movements and progressive dementia), achondroplasia (a genetic disorder resulting in disordered growth and abnormal body proportion), and polycystic kidney disease (a genetic disorder involving the growth of multiple, bilateral, grapelike

Normal Mother

clusters of fluid-filled cysts in the kidneys that eventually compress and replace functioning renal tissue). AUTOSOMAL RECESSIVE INHERITANCE DISORDERS Autosomal recessive inherited disorders occur when two copies of the mutant or abnormal gene in the homozygous state are necessary to produce the phenotype. In other words, two abnormal genes are needed for the individual to demonstrate signs and symptoms of the disorder. Both parents of the affected person must be heterozygous carriers of the gene (clinically normal but carriers of the gene). Offspring of two carriers of the abnormal gene have a 25% chance of inheriting two normal genes; a 50% chance of inheriting one normal gene and one abnormal gene (carrier); and a 25% chance of inheriting two abnormal genes (and, thus, the disorder) (Fig. 10.14) (Conley, 2010; Scott & Lee, 2011). Affected people are usually present in only one generation of the family. Females and males are equally affected and a male can pass the disorder on to his son. The chance that any two parents will both be carriers of the mutant gene is increased if the couple has consanguinity (relationship by blood or common ancestry) (Scott & Lee, 2011). Common types of genetic disorders that follow the autosomal recessive inheritance pattern include cystic fibrosis (a genetic disorder involving generalized dysfunction of the exocrine glands), phenylketonuria (a disorder involving a deficiency in a liver enzyme that leads to the inability to process the essential amino acid phenylalanine), TaySachs disease (a disorder due to insufficient activity of the enzyme hexoaminodase, which is necessary for the

Affected Father

n n D n

n n

Affected Female

Normal Male

Carrier Mother

D n D n

Affected Male

FIGURE 10.13 Autosomal dominant inheritance.

Carrier Father

N d n n

Normal Female

N N

Normal Male

N d

Carrier Female

N d N d

Carrier Male

FIGURE 10.14 Autosomal recessive inheritance.

d d

Affected Female



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breakdown of certain fatty substances in the brain and nerve cells), and sickle cell disease (a genetic disorder in which the red blood cells carry an ineffective type of hemoglobin instead of the normal adult hemoglobin).

Normal Father

X-LINKED INHERITANCE DISORDERS X-linked inherited disorders are those associated with altered genes present on the X chromosome. They differ from autosomal disorders. If a male inherits an X-linked altered gene, he will express the condition. This is because a male has only one X chromosome, therefore all the genes on his X chromosome will be expressed (the Y chromosome carries no normal allele to compensate for the altered gene). Because females inherit two X chromosomes, they can be either heterozygous or homozygous for any allele. Therefore, X-linked disorders in females are expressed similarly to autosomal disorders. X-LINKED RECESSIVE INHERITANCE Most X-linked disorders demonstrate a recessive pattern of inheritance (Beery & Workman, 2012; Conley, 2010). There are more affected males than females because all the genes on a man’s X chromosome will be expressed since a male has only one X chromosome (Scott & Lee, 2011). On the other hand, a female will usually need two abnormal X chromosomes to exhibit the disease and one normal and one abnormal X chromosome to be a carrier of the disease. There is no male-to-male transmission (since no X chromosome from the male is transmitted to male offspring), but any man who is affected with an X-linked recessive disorder will have carrier daughters. If a woman is a carrier, there is a 25% chance she will have an affected son, a 25% chance that her daughter will be a carrier, a 25% chance that she will have an unaffected son, and a 25% chance her daughter will be a noncarrier (Fig. 10.15) (Conley, 2010). Common types of genetic disorders that follow X-linked recessive inheritance patterns include hemophilia, color blindness, and Duchenne muscular dystrophy (Conley, 2010). X-LINKED DOMINANT INHERITANCE X-linked dominant inheritance occurs when a male has an abnormal X chromosome or a female has one abnormal X chromosome. All of the daughters and none of the sons of an affected male will inherit the condition, while both male and female offspring of an affected woman have a 50% chance of inheriting the condition (Fig. 10.16) (Scott & Lee, 2011). Males are more severely affected than females. Many X-linked dominant disorders have lethal results in males (Scott & Lee, 2011). In females, even though the gene is dominant, having a second normal X gene offsets the effects of the dominant gene to some extent resulting in decreasing severity of the disorder. X-linked dominant disorders are rare; examples include hypophosphatemic (vitamin D–resistant) rickets and fragile X syndrome.

Carrier Mother

XY

Normal Male

Normal Female

XX

Carrier Female

Affected Male

FIGURE 10.15 X-linked recessive inheritance.

Normal Father

Affected Mother

X Y

Normal Male

Affected Female

X X

Affected Male

Normal Female

FIGURE 10.16 X-linked dominant inheritance.

Multifactorial Inheritance Disorders Many of the common congenital malformations, such as cleft lip, cleft palate, spina bifida, pyloric stenosis, clubfoot, congenital hip dysplasia, and cardiac defects, are

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attributed to multifactorial inheritance (Conley, 2010; Scott & Lee, 2011). These conditions are thought to be caused by multiple gene and environmental factors. That is, a combination of genes from both parents, along with unknown environmental factors, produces the trait or condition. An individual may inherit a predisposition to a particular anomaly or disease. The anomalies or diseases vary in severity, and often a sex bias is present. For example, pyloric stenosis is seen more often in males, while congenital hip dysplasia is much more likely to occur in females. Multifactorial conditions tend to run in families, but the pattern of inheritance is not as predictable as with single-gene disorders. The chance of recurrence is also less than in single-gene disorders, but the degree of risk is related to the number of genes in common with the affected individual. The closer the degree of relationship, the more genes an individual has in common with the affected family member, resulting in a higher chance the individual’s offspring will have a similar defect. In multifactorial inheritance the likelihood that both identical twins will be affected is not 100%, indicating that there are nongenetic factors involved.

Nontraditional Inheritance Patterns Molecular studies have revealed that some genetic disorders are inherited in ways that do not follow the typical patterns of dominant, recessive, X-linked, or multifactorial inheritance. Examples of nontraditional inheritance patterns include mitochondrial inheritance and genomic imprinting. As the science of molecular genetics advances and more is learned about inheritance patterns, other nontraditional patterns of inheritance may be discovered or found to be relatively common. MITOCHONDRIAL INHERITANCE Certain diseases result from mutations in the mitochondrial DNA. Mitochondria (the part of the cell responsible for energy production) are inherited almost exclusively from the mother. Therefore, mitochondrial inheritance is usually passed from the mother to the offspring, regardless of the offspring’s sex (differentiating mitochondrial inheritance from X-linked recessive inheritance). These mutations are often deletions and abnormalities and are often seen in one or more organs, such as the brain, eye, and skeletal muscle. They are often associated with energy deficits in cells with high energy requirements, such as nerve and muscle cells. These disorders tend to be progressive and the age of onset can vary from infancy to adulthood. There is an extreme amount of variability in symptoms within a family. Examples of disorders that follow mitochondrial inheritance include Kearns-Sayre syndrome (a neuromuscular disorder) and Leber’s hereditary optic neuropathy (which causes progressive visual impairment).

GENOMIC IMPRINTING Another nontraditional inheritance pattern results from a process called genomic imprinting. Genomic imprinting plays a critical role in fetal growth and development and placental functioning. It is a phenomenon by which the expression of a gene is determined by its parental origin. In genomic imprinting both the maternal and paternal alleles are present, but only one is expressed; the other is inactive. Genomic imprinting does not alter the genetic sequence itself, but affects the phenotype observed. In these cases, the altered genes in a certain region of the genome have very different expressions depending on whether they were inherited from the mother or the father. Several human syndromes are known to be associated with defects in gene imprinting. Disorders that result from a disruption of imprinting usually involve a growth phenotype and include varying degrees of developmental problems. Common examples include Prader-Willi syndrome (a condition resulting in severe hypotonia and hyperphagia, leading to obesity and intellectual disability), Angelman syndrome (a neurodevelopmental disorder associated with intellectual disability, jerky movements and seizures), and Beckwith-Wiedemann syndrome (characterized by somatic overgrowth, congenital malformations, and a predisposition to embryonic neoplasia).

Chromosomal Abnormalities In some cases of genetic disorders, the abnormality occurs due to problems with the chromosomes. Chromosomal abnormalities do not follow straightforward patterns of inheritance. Although some chromosomal disorders can be inherited, most others occur due to random events during the formation of reproductive cells or in early fetal development. Sperm and egg cells each have 23 unpaired chromosomes. When they unite during conception they form a fertilized egg with 46 chromosomes. Sometimes before pregnancy begins, an error has occurred during the process of cell division, leaving an egg or sperm with too many or too few chromosomes. If this egg or sperm cell joins with a normal egg or sperm cell, the resulting embryo has a chromosomal abnormality. Chromosomal abnormalities can also occur due to an error in the structure of the chromosome. Small pieces of the chromosome may be deleted, duplicated, inverted, misplaced, or exchanged with part of another chromosome. Most chromosomal abnormalities occur due to an error in the egg or sperm. Therefore, the abnormality is present in every cell of the body. Some abnormalities can happen after fertilization during mitotic cell division and result in mosaicism. Mosaicism or mosaic form is when the chromosomal abnormalities do not show up in every cell; only some cells or tissues carry the abnormality. In mosaic forms of the disorder, the symptoms are usually less severe than if all the cells were abnormal.



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Chromosomal abnormalities occur in 1% of live births (Bacino & Lee, 2011). There is a much higher frequency of chromosomal abnormalities in spontane­ ous abortions and stillbirths (Descartes & Carroll, 2011). Congenital anomalies and intellectual disability are often ­associated with chromosomal abnormalities (Descartes & Carroll, 2011). These abnormalities occur on autosomal or non-sex chromosomes as well as sex chromosomes and can result from abnormalities of either chromosome number or chromosome structure. As mentioned, a karyotype is a pictorial analysis of chromosomes. It depicts a systematic arrangement of chromosomes of a single cell by pairs (see Figure 10.12). Karyotyping is often used in prenatal testing to diagnose or predict genetic diseases.

Abnormalities of Chromosome Number Chromosomal abnormalities of number often result due to nondisjunction (failure of separation of the chromosome pair during cell division, meiosis, or mitosis). Few chromosomal numerical abnormalities are compatible with full-term development and most result in spontaneous abortion (Descartes & Carroll, 2011). There are some numerical abnormalities that do support development to term because the chromosome on which the abnormality is present carries relatively few genes (such as chromosome 13, 18, 21, or X). Two common abnormalities of chromosome number are monosomies or trisomies. In monosomies there is only one copy of a particular chromosome instead of the usual pair (an entire single chromosome is missing). In these cases, all fetuses spontaneously abort in early pregnancy. Survival is seen only in mosaic forms of these disorders. In trisomies, there are three of a particular chromosome instead of the usual two (an entire single chromosome is added). The most common trisomies include trisomy 21 (Down syndrome), trisomy 18, and trisomy 13. ­Figure 10.17 shows the karyotype of a child with Down syndrome. (See Chapter 51 for a detailed discussion of

these disorders.) Trisomies may be present in every cell or may present in the mosaic form.

Abnormalities of Chromosome Structure Abnormalities of chromosome structure usually occur when there is a breakage and loss of a portion of one or more chromosomes, and during the repair process the broken ends are rejoined incorrectly. Structural abnormalities usually lead to having too much or too little genetic material. Altered chromosome structure can take on several forms. Deletions occur when a portion of the chromosome is missing or deleted, resulting in a loss of that portion of the chromosome. Duplications are seen when a portion of the chromosome is duplicated and an extra chromosomal segment is present. Clinical findings vary depending on how much chromosomal material is involved. Inversions occur when a portion of the chromosome breaks off at two points and is turned upside down and reattached; therefore, the genetic material is inverted. With inversion, there is no loss or gain of chromosomal material and carriers are phenotypically normal, but they do have an increased risk for miscarriage and having chromosomally abnormal offspring (Descartes & Carroll, 2011). Ring chromosomes are seen when a portion of a chromosome has broken off in two places and formed a circle or ring. The most clinically significant structural abnormality is a translocation. This occurs when a potion of one chromosome is transferred to another chromosome and an abnormal rearrangement is present. Structural abnormalities can be balanced or unbalanced. Balanced abnormalities involve the rearrangement of genetic material with neither an overall gain nor loss. Individuals who inherit a balanced structural abnormality are usually phenotypically normal but are at a higher risk for miscarriages and having chromosomally abnormal offspring. Examples of structural rearrangements that can be balanced include inversions, translocation, and ring chromosomes. Unbalanced structural abnormalities are similar to numerical abnormalities because genetic material is either gained or lost. Unbalanced structural abnormalities can encompass several genes and result in severe clinical consequences.

Sex Chromosome Abnormalities

FIGURE 10.17 Karyotype of a child with Down syndrome.

Chromosomal abnormalities can also involve sex chromosomes. These cases are usually less severe in their clinical effects than autosomal chromosomal abnormalities. Sex chromosome abnormalities are gender-­specific and involve a missing or extra sex chromosome. They affect sexual development and may cause infertility, growth abnormalities, and possibly behavioral and learning problems. However, many affected people lead essentially normal lives. Examples are Turner syndrome

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(in females) and Klinefelter’s syndrome in males (see Chapter  51 for a more detailed discussion of these disorders).

GENETIC EVALUATION AND COUNSELING Genetic counseling is a communication and educational process where the genetic influence of health is explained along with information regarding a specific genetic disorder, its transmission, inheritance, and options available in management and family planning (Lee, 2011). There are a variety of reasons a person should be referred for genetic counseling (Box 10.2). In many cases, geneticists and genetic counselors provide information to families regarding genetic diseases. However, an experienced family physician, pediatrician, or nurse who has received special training in genetics may also

provide the information. A genetic consultation involves evaluation of an individual or a family. Its purpose is to confirm, diagnose, or rule out genetic conditions; identify medical management issues; calculate and communicate genetic risks to a family; discuss ethical and legal issues; and assist in providing and arranging psychosocial support. Genetic counselors serve as educators and resource persons for other health care providers and the general public. The ideal time for genetic counseling is before conception. Preconception counseling allows couples to identify and reduce potential pregnancy risks, plan for known risks, and establish early prenatal care. Unfortunately, many women delay seeking prenatal care until their second or third trimester, after the crucial time of organogenesis. Therefore, it is important that preconception counseling is offered to all women as they seek health care throughout their childbearing years, especially if they are contemplating pregnancy. This requires health care providers to take an active role.

BOX 10.2

THOSE WHO MAY BENEFIT FROM GENETIC COUNSELING • Maternal age 35 years or older when the baby is born • Paternal age 50 years or older • Previous child, parents, or close relatives with an inherited disease, congenital anomalies, metabolic disorders, developmental disorders, or chromosomal abnormalities • Consanguinity or incest • Pregnancy screening abnormality, including alphafetoprotein, triple/quadruple screen, amniocentesis, or ultrasound • Stillborn with congenital anomalies • Two or more pregnancy losses • Teratogen exposure or risk • Concerns about genetic defects that occur frequently in their ethnic or racial group (e.g., those of African descent are most at risk for having a child with sickle cell anemia) • Abnormal newborn screening • Child born with one or more major malformations in a major organ system • Child with abnormalities of growth • Child with developmental delay, intellectual disability, blindness, or deafness Adapted from Conley, Y. P. (2010). Genetics and health applications. In S. M. Nettina (ed.), Lippincott manual of nursing practice (9th ed.) (chap. 4, pp. 35–46). Philadelphia: Lippincott Williams & Wilkins; Lee, B. (2011). Integration of Genetics into Pediatric Practice In R. M. Kliegman, B. F. Stanton, J.W. St. Geme, N.F. Schor, & R.E. Behrman, (Eds.), Nelson’s textbook of pediatrics (19th ed., p. 376–80). Philadelphia: Saunders

A

Consider This

s I waited for the genetic counselor to come into the room, my mind was filled with numerous fears and questions. What does an inconclusive amniocentesis really mean? What if this pregnancy produced an abnormal baby? How would I cope with a special child in my life? If only I had gone to the midwife sooner when I thought I was pregnant, but still in denial. Why did I wait so long to admit this pregnancy and get prenatal care? If only I had started to take my folic acid pills when prescribed. Why didn’t I research my family’s history to know of any hidden genetic conditions? What about my sister with a Down syndrome child? What must I have been thinking? I guess I could play the “what-if” game forever and never come up with answers. It was too late to do anything about this pregnancy because I was in my last trimester. I started to pray silently when the counselor opened the door. . . . Thoughts: This woman is reviewing the last several months, looking for answers to her greatest fears. Inconclusive screenings can introduce emotional torment for many women as they wait for validating results. Are these common thoughts and fears for many women facing potential genetic disorders? What supportive interventions might the nurse offer?

Preconception counseling plays a key role in preparing for a pregnancy. In couples with a history of recurrent early pregnancy loss, counseling is of particular importance because women are invariably more distressed and require reassurance to avoid future pregnancy losses. Several interventions ranging from genetic testing to lifestyle changes and medications may have a



positive effect on the chances of a successful pregnancy. Early pregnancy monitoring and support increases the chance of a live birth and helps to predict potential future pregnancy complications. Recent research suggests that events that occur in the uterine decidua, even before a woman knows she is pregnant, may have a significant impact on fetal growth and the outcome of pregnancy. With this in mind, shifting future research and clinical practice to focus on the periconceptual period and the very early stages of pregnancy should offer significant benefits to the health of both the mother and her infant. The overall aim should be to effectively use every pregnancy as the health care opportunity of two lifetimes (Saravelos & Regan, 2011). Preconception screening and counseling can raise serious ethical and moral issues for a couple. The results of prenatal genetic testing can lead to the decision to terminate a pregnancy, even if the results are not conclusive but indicate a strong possibility that the child will have an abnormality. The severity of the abnormality may not be known, and some may find the decision to terminate unethical. Another difficult situation that provides an example of the ethical and moral issues surrounding genetic screening and counseling involves disorders that affect only one gender of offspring. A mother may find she is a carrier of a gene for a disorder for which there is no prenatal screening test available. In these cases the couple may decide to terminate any pregnancy where the fetus is the affected sex, even though there is a 50% chance that the child will not inherit the disorder. In these situations, the choice is the couple’s and information and support must be provided in a nondirective manner. Genetic counseling is particularly important if a congenital anomaly or genetic disease has been diagnosed prenatally or when a child is born with a lifethreatening congenital anomaly or genetic disease. In these cases families need information urgently so they can make immediate decisions. If a diagnosis with genetic implications is made later in life, if a couple with a family history of a genetic disorder or a previous child with a genetic disorder is planning a family, or if there is suspected teratogen exposure, urgency of information is not such an issue. In these situations, the family needs to take in all the information and explore their options. This may occur during several meetings over a longer period of time. A teratogen is any substance, organism, physical agent, or deficiency state present during gestation that is capable of inducing abnormal postnatal structure or function by interfering with normal embryonic and fetal development (March of Dimes, 2012c). Susceptibility to teratogenic agents is dependent on the timing of the exposure and the developmental stage of the embryo or fetus. Teratogens include alcohol, certain drugs/medications, infections, and certain chemicals.

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59 yr diabetes

56 yr hypertension

31 yr 27 yr

3 mo 6 yr

37 yr 32 yr

5 yr 6 yr asthma

Unaffected male, female Affected male, female Deceased

62 yr heart attack

8 yr

58 yr

15 yr drowning

42 yr 44 yr

9 yr 14 yr

Siblings, listed left to right by birth order Mating or marriage

FIGURE 10.18 A pedigree is a diagram made using symbols that demonstrates the links between family members and focuses on medical and health information for each relative.

Genetic counseling involves extensive information gathering about birth history, past medical history, and current health status as well as a family history of congenital anomalies, mental retardation, genetic diseases, reproductive history, general health, and causes of death. A detailed family history is imperative and in most cases will include the development of a pedigree, which is like a family tree (Fig. 10.18). Information is ideally gathered on three generations, but if the family history is complicated, information from more distant relatives may be needed. Families receiving genetic counseling should be told that this information will be necessary so that they can discuss these sensitive issues with family members in advance. When necessary, medical records may be requested for family members, especially those who have a genetic disorder, to help ensure accuracy of the information. Sometimes the process of preparing a pedigree may reveal information that is not known by all family members, such as an adoption, a child conceived through in vitro fertilization, or a husband not being the father of a baby. Therefore, it is extremely important to take steps to maintain confidentiality. After careful analysis of the data obtained, referral to a genetic counselor when indicated is appropriate. Medical genetic knowledge has increased dramatically over the past few decades. This has greatly expanded the role of the genetic counselor. It is possible not only to detect specific diseases with genetic mutations, but also to test for a genetic predisposition to various diseases or conditions and certain physical characteristics. This leads to complex ethical, moral, and social issues. Health care providers need to maintain privacy and confidentiality and administer care in a nondiscriminatory manner while maintaining sensitivity to cultural differences. It is essential to respect individual’s autonomy and present information in a nondirective manner.

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Nursing Roles and Responsibilities The nurse is likely to interact with the client in a variety of ways related to genetics—taking a family history, scheduling genetic testing, explaining the purposes of all screening and diagnostic tests, answering questions, and addressing concerns raised by family members. Nurses are often the first health care providers to encounter women with preconception and prenatal issues. Nurses play an important role in beginning the preconception counseling process and referring women and their partners for further genetic testing when indicated. An accurate and thorough family history is an essential part of preconception counseling. Nurses in any practice setting can obtain a client’s history during the initial encounter. The purpose is to gather client and family information that may provide clues as to whether the client has a genetic trait, inherited condition, or inherited predisposition (Hartley, Greenberg, & Mhanni, 2011). At a basic level, all nurses should be able to take a family medical history to help identify those at risk for genetic conditions, and then initiate a referral when appropriate. Box  10.3 presents examples of focused

BOX 10.3

FOCUSED HEALTH ASSESSMENT: GENETIC HISTORY What was the cause and age of death for deceased family members? Does any consanguinity exist between relatives? Do any serious illnesses or chronic conditions exist? If so, what was the age of onset? Do any female family members have a history of miscarriages, stillbirths, or diabetes? Do any female members have a history of alcohol or drug use during pregnancy? What were the ages of female members during childbearing, especially if older than 35? Do any family members have mental retardation or developmental delays? Do any family members have a known or suspected metabolic disorder such as PKU? Do any family members have an affective disorder such as bipolar disorder? Have any close relatives been diagnosed with any type of cancer? What is your ethnic background (explore as related to certain disorders)? Do any family members have a known or suspected chromosomal disorder? Do any family members have a progressive neurologic disorder? Source: Beery & Workman (2012).

assessment questions that can be used. Based on the information gathered during the history, the nurse must decide whether a referral to a genetic specialist is necessary or whether further evaluation is needed. Families identified with genetic issues need unique clinical care including management of acute illnesses, screening for long-term complications, discussion of the etiology of the condition, connections to social supports, and clarification of the recurrence risks and prenatal testing and treatment options (­Hartley et al., 2011). Prenatal testing to assess for genetic risks and defects might be used to identify genetic disorders. These tests are described in Common Laboratory and Diagnostic Tests 10.1.

Remember Robert and Kate Shafer? Based on the information gathered from their genetic history, they were referred to a genetic specialist. What prenatal tests might be ordered to assess their risk for genetic disorders? What would be the nurse’s role related to genetic counseling?

Nurses working with families involved with genetic counseling typically have certain responsibilities. These include: • Using interviewing and active listening skills to identify genetic concerns • Knowing basic genetic terminology and inheritance patterns • Explaining basic concepts of probability and disorder susceptibility • Safeguarding the privacy and confidentiality of clients’ genetic information • Providing complete informed consent to facilitate decisions about genetic testing • Discussing costs of genetic services and the benefits and risks of using health insurance to pay for genetic services, including potential risks of discrimination • Recognizing and defining ethical, legal, and social issues • Providing accurate information about the risks and benefits of genetic testing • Providing culturally appropriate methods to convey genetic information • Monitoring clents’ emotional reactions after receiving genetic analysis • Providing information on appropriate local support groups • Knowing their own limitations and making appropriate referrals (Beery & Workman, 2012) Talking with families who have recently been diagnosed with a genetic disorder or who have had a child



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COMMON LABORATORY AND DIAGNOSTIC TESTS 10.1

Test

Description

PRENATAL TESTS TO ASSESS RISK FOR GENETIC DISORDERS

Indication

Increased levels might indicate a neuAlpha-fetoprotein A sample of the woman’s blood is ral tube defect, Turner syndrome, tedrawn to evaluate plasma protein tralogy of Fallot, multiple gestation, that is produced by the fetal liver, omphalocele gastroschisis, or hydroyolk sac, and GI tract, and crosses cephaly. Decreased levels might indifrom the amniotic fluid into the cate Down syndrome or trisomy 18 maternal blood

Timing Typically performed between 15 and 18 weeks’ gestation

Amniocentesis

Amniotic fluid aspirated from the amniotic sac; safety concerns include infection, pregnancy loss, and fetal needle injuries

To perform chromosome analysis, Usually performed alpha-fetoprotein, DNA markers, viral between 15 and studies, karyotyping; and identify 20 weeks’ gestation inborn errors of metabolism to allow for adequate amniotic fluid volume to accumulate; results take 2 to 4 weeks

Chorionic villus sampling

Removal of small tissue specimen from the fetal portion of the placenta, which reflects the fetal genetic makeup; main complications include severe transverse limb defects and spontaneous pregnancy loss

To detect fetal karyotype, sickle cell anemia, phenylketonuria, Down syndrome, Duchenne muscular dystrophy, and numerous other genetic disorders

Typically performed between 10 and 12 weeks’ gestation, with results available in less than 1 week

Percutaneous Insertion of a needle directly into umbilical blood a fetal umbilical vessel under ulsampling trasound guidance; two potential complications: fetal hemorrhage and risk of infection

Generally performed Used for prenatal diagnosis of inherited blood disorders such as he­after 16 weeks’ mophilia A, karyotyping, detection gestation of fetal infection, determination of acid–base status, and assessment and treatment of isoimmunization

Fetal nuchal translucency (FNT)

An intravaginal ultrasound that measures fluid collection in the subcutaneous space between the skin and the cervical spine of the fetus

To identify fetal anomalies; abnormal fluid collection can be associated with genetic disorders (trisomies 13, 18, and 21), Turner syndrome, cardiac deformities, and/or physical anomalies. When the FNT is greater than 2.5 mm, the measurement is considered abnormal

Performed between 10 and 14 weeks’ gestation

Level II ultrasound/fetal scan

Use of high-frequency sound waves to visualize the fetus

Enables evaluation of structural changes to be identified early

Typically performed after 18 weeks’ gestation

Triple and quad screening tests

Triple screening includes alphafetoprotein, estriol, and betahCG; quad screening includes alpha-fetoprotein, estriol, beat-hCG, and inhibin A

To identify risk for Down syndrome, neural tube defects, and other chromosomal disorders. Elevated hCG combined with lower-than-normal estriol and MSAFP levels indicate increased risk for Down syndrome or other trisomy condition

Performed between 15 and 18 weeks’ gestation

Preimplantation genetic diag­ nosis (PGD)

Genetic testing of embryos produced through in vitro fertiliza­ tion (IVF)

Identifies embryos carrying specific genetic alterations that can cause disease, and transfer those without genetic alterations into the woman’s uterus to start a pregnancy. Prevents inheritable genetic disease before implantation

Usually on day 3 after egg retrieval and 2 days after fertilization, a single blastomere is removed from the developing embryo to be evaluated

Sources: Van Leeuwen, Poelhuis-Leth, & Bladh (2011); Cunningham et al. (2010); Gilbert (2011). Van Leeuwen, A. M., Poelhuis-Leth, D., & Bladh, M. L. (2011). Davis’s comprehensive handbook of laboratory & diagnostic tests with nursing ­implications (4th ed.). Philadelphia, PA: F.A. Davis Company. Cunningham, F. G., Leveno, K. J., Bloom, S. L., Hauth, J. C., Rouse, D. J., & Spong, C. Y. (2010). William’s obstetrics (23rd ed.). New York: McGraw Medical. Gilbert, E. S. (2011). Manual of high-risk pregnancy and delivery (5th ed.). St. Louis: Mosby Inc.

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born with congenital anomalies is very difficult. Many times the nurse may be the one who has first contact with these parents and will be the one to provide followup care. Genetic disorders are significant, life-changing, and possibly life-threatening situations. The information is highly technical and the field is undergoing significant technologic advances. Nurses need an understanding of who will benefit from genetic counseling and must be able to discuss the role of the genetic counselor with families. The nurse wants to ensure that families at risk are aware that genetic counseling is available before they attempt to have another baby.

Based on the results of their genetic tests, Robert and Kate are placed at moderate risk for having an infant with an autosomal recessive genetic disorder. The couple asks the nurse what all of this means. What information should the nurse provide about concepts of probability and disorder susceptibility for this couple? How can the nurse help this couple to make knowledgeable decisions concerning their reproductive future?

Nurses play an essential role in providing emotional support to the family through this challenging time. Genetics permeates all aspects of health care. Today, everyone is embracing quality and evidence-based care. Nurses who have an understanding of genetics and genomics will possess the foundation to provide quality, evidencebased care especially with follow-up counseling after the couple or family has been to the genetic specialist.

Take Note! Nurses need to be actively engaged with clients and their families and help them consider the facts, values, and context in which they are making decisions. Nurses need to be open and honest with families as they discuss these sensitive and emotionally laden choices. The nurse is in an ideal position to help families review what has been discussed during the genetic counseling sessions and to answer any additional questions they might have. Referral to appropriate agencies, support groups, and resources, such as a social worker, a chaplain, or an ethicist, is another key role when caring for families with suspected or diagnosed genetic disorders. Couples need unique clinical care which includes screening for genetic disorders, discussion of the etiology of a potential condition, connections to social supports, and clarification of the recurrence risks and prenatal testing and treatment options. Nurses need to be involved in all aspects of this care.

KEY CONCEPTS Fertilization, which takes place in the outer third of the ampulla of the fallopian tube, leads to the formation of a zygote. The zygote undergoes cleavage, eventually implanting in the endometrium about 7 to 10 days after conception. Three embryonic layers of cells are formed and include the ectoderm, which forms the central nervous system, special senses, skin, and glands; the mesoderm, which forms the skeletal, urinary, circulatory, and reproductive systems; and the endoderm, which forms the respiratory system, liver, pancreas, and digestive system. Amniotic fluid surrounds the embryo and increases in volume as the pregnancy progresses, reaching approximately 1 L in volume by term. At no time during pregnancy is there any direct connection between the blood of the fetus and the blood of the mother, so there is no mixing of blood. A specialized connective tissue known as Wharton’s jelly surrounds the three blood vessels in the umbilical cord to prevent compression, which would choke off the blood supply and nutrients to the growing life inside. The placenta protects the fetus from immune attack by the mother, removes waste products from the fetus, induces the mother to bring more food to the placenta, and, near the time of delivery, produces hormones that mature fetal organs in preparation for life outside the uterus. The purpose of fetal circulation is to carry highly oxygenated blood to vital areas (heart and brain) while first shunting it away from less vital ones (lungs and liver). Humans have 46 paired chromosomes that are found in all cells of the body, except the ovum and sperm cells, which have just 23 chromosomes. Each person has a unique genetic constitution, or genotype. Research from the Human Genome Project has provided a better understanding of the genetic contribution to disease. Genetic disorders can result from abnormalities in patterns of inheritance or chromosomal abnormalities involving chromosomal number or structure. Autosomal dominant inheritance occurs when a single gene in the heterozygous state is capable of producing the phenotype. Autosomal recessive inheritance occurs when two copies of the mutant or abnormal gene in the homozygous state are necessary to produce the phenotype. X-linked



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inheritance disorders are those associated with altered genes present on the X chromosome. They can be dominant or recessive. Multifactorial inheritance is thought to be caused by multiple genetic and environmental factors. In some cases of genetic disorders, a chromosomal abnormality occurs. Chromosomal abnormalities do not follow straightforward patterns of inheritance. These abnormalities occur on autosomal as well as sex chromosomes and can result from changes in the number or structure of the chromosomes. Genetic counseling involves evaluation of an individual or a family. Its purpose is to confirm, diagnose, or rule out genetic conditions; identify medical management issues; calculate and communicate genetic risks to a family; discuss ethical and legal issues; and assist in providing and arranging psychosocial support. Legal, ethical, and social issues can arise related to genetic testing and may include the privacy and confidentiality of genetic information, who should have access to personal genetic information, psychological impact and stigmatization due to individual genetic differences, use of genetic information in reproductive decision making and reproductive rights, and whether testing should be performed if no cure is available. Preconception screening and counseling can raise serious ethical and moral issues for a couple. The results of prenatal genetic testing can lead to the decision to terminate a pregnancy. Nurses play an important role in beginning the preconception counseling process and referring women and their partners for further genetic information when indicated. Many times the nurse is the one who has first contact with these women and will be the one to provide follow-up care. Nurses need to have a solid understanding of who will benefit from genetic counseling and be able to discuss the role of the genetic counselor with families, ensuring that families at risk are aware that genetic counseling is available before they attempt to have another baby. Nurses play an essential role in providing emotional support and referrals to appropriate agencies, support groups, and resources when caring for families with suspected or diagnosed genetic disorders. Nurses can assist clients with their decision making by referring them to a social worker, chaplain, or ethicist.

References Alberts, B. (2011). Lessons from genomics. Science 331(6017), 511. Alvero, R., & Schlaff, W. D. (2012). Reproductive endocrinology and infertility: The requisites in obstetrics and gynecology (2nd ed.). St. Louis: Mosby Elsevier American Nurses Association [ANA]. (2009). Essentials of genetic and genomic nursing: Competencies, curricula guidelines, and outcome indicators (2nd ed.). Silver Springs, MD: American Nurses Association. Bacino, C.A. & Lee, B. (2011). Chapter 76: Cytogenetics In R. M. ­Kliegman, B. F. Stanton, J.W. St. Geme, N.F. Schor, & R.E. B ­ ehrman, (Eds.), Nelson’s textbook of pediatrics (19th ed., p. 394–414). P ­ hiladelphia: Saunders Battista, R., Blancquaert, I., Laberge, A., van Schendel, N., & Leduc, N. (2012). Genetics in health care: An overview of current and e­ merging models. Public Health Genomics, 15(1), 34–45. Beery, T. A., & Workman, M. L. (2011). Genetics and genomics in ­nursing and health care. Philadelphia, PA: F.A. Davis. Beery, T. H., & Workman, M. L. (2012). Genetics and genomics in ­nursing and health care. Philadelphia, PA: F.A. Davis. Behrman, R. E., Kliegman, R. M., Stanton, B. F., St. Geme, J., & Schor, N. (2011). Nelson’s textbook of pediatrics (19th ed.). Philadelphia, PA: Elsevier Health Sciences. Bennett, P., & Williamson, C. (2010). Basic science in obstetrics & gynecology (4th ed.). Oxford, UK: Elsevier Health Sciences Blackburn, S. T. (2013). Maternal, fetal and neonatal physiology (4th ed.). Philadelphia: Saunders. Burke, W., Tarini, B., Press, N., & Evans, J. (2011). Genetic screening. Epidemiologic Reviews, 33, 148–164. Calne, R., Gan, S., & Lee, K. (2010). Stem cell and gene therapies for diabetes mellitus. Nature Reviews. Endocrinology, 6(3), 173–177. Carcio, H. A., & Secor, M. C. (2010). Advanced health assessment of women (2nd ed.). New York: Springer Publishing Company, Inc. Centers for Disease Control and Prevention. (2011). Facts about birth effects. Retrieved February 29, 2012, from http://www.cdc.gov/ ncbddd/birthdefects/facts.html Chen, H. (2011a). Cri du chat syndrome. eMedicine. Available at http:// emedicine.medscape.com/article/942897-overview –—. (2011b). Klinefelter syndrome. eMedicine. Available at http:// emedicine.medscape.com/article/945649-overview Conley, Y. P. (2010). Genetics and health applications. In S. M. Nettina (ed.), Lippincott manual of nursing practice (9th ed.) (chap. 4, pp. 35–46). Philadelphia: Lippincott Williams & Wilkins. Creatsas, G., Chrousos, G. P., & Mastorakos, G. (2010). Women’s health and disease: Gynecologic and reproductive issues. Malden, MA: Wiley-Blackwell. Cunningham, F. G., Leveno, K. J., Bloom, S. L., Hauth, J. C., Rouse, D. J., & Spong, C. Y. (2010). William’s obstetrics (23rd ed.). New York: McGraw Medical. D’ Amico, D. (2012). Health and physical assessment in nursing (2nd ed.). Upper Saddle River, NJ: Pearson Prentice Hall Dayal, M. B., & Athanasiadia, I. (2011). Preimplantation genetic diagnosis. eMedicine. [Online] Available at http://emedicine.medscape .com/article/273415-overview#aw2aab6b3 Edelman, C. L., & Mandle, C. L. (2010). Health promotion throughout the lifespan (7th ed.). St. Louis: Mosby Elsevier. Eisenstein, M. (2011). Genetics: Finding risk factors. Nature, 475(7355), S20–S22. Gilbert, E. S. (2011). Manual of high-risk pregnancy and delivery (5th ed.). St. Louis: Mosby Inc. Gregg, A. R., & Simpson, J. L. (2010). Genetic screening and counseling: An issue of obstetrics and gynecology clinics. St. Louis: Saunders Elsevier. Hartley, J., Greenberg, C., & Mhanni, A. (2011). Genetic counseling in a busy pediatric metabolic practice. Journal of Genetic Counseling, 20(1), 20–22. Herzog, R., Cao, O., & Srivastava, A. (2010). Two decades of clinical gene therapy—Success is finally mounting. Discovery Medicine, 9(45), 105–111. Human Genome Management Information System. (2010). Human Genome Project information. Available at http://www.ornl.gov/sci/ techresources/Human_Genome/home.shtml#index. International Human Genome Sequencing Consortium. (2009). NIH launches Human Microbiome Project. Available at http://www .genome.gov/26524200

332   U N I T 3  Pregnancy Jarvis, C. (2012) Physical examination & health assessment. (6th ed.), St. Louis, MO: Saunders Elsevier. Jenkins, J. (2011). Family history as a genetic assessment tool: Where are the resources? American Nurse Today, 6(10),1–3. Jewell, J. (2011). Fragile X syndrome. eMedicine. Available at http:// emedicine.medscape.com/article/943776-overview Jorde, L. B., Carey, J. C., & Bamshad, M. J. (2010). Medical genetics (4th ed.). St. Louis: Mosby Elsevier. Kochhar, S. (2011). Screening for Down’s syndrome. Independent Nurse, 25–26. Lee, B. (2011). Chapter 72: Integration of Genetics into Pediatric Practice In R. M. Kliegman, B. F. Stanton, J.W. St. Geme, N.F. Schor, & R.E. Behrman, (Eds.), Nelson’s textbook of pediatrics (19th ed., p. 376–80). Philadelphia: Saunders. Lea, D., Skirton, H., Read, C. Y., & Williams, J. K. (2011). Implications for educating the next generation of nurses on genetics and genomics in the 21st century. Journal of Nursing Scholarship, 43(1), 3–12. Lea, M. (2010). Genetic counseling. Available at http://nursingbuzz .com/genetic-counseling/ Lewis, J. (2011). Genetics and genomics: Impact on perinatal nursing. The Journal of Perinatal & Neonatal Nursing, 25(2), 144–147. Lewis, R. (2011) Human genetics: Concepts and applications (10th ed.). New York: McGraw-Hill Companies, Incorporated. Lloyd, R. V. (2010). Endocrine pathology: Differential diagnosis and molecular advances (2nd ed.). New York: Springer Publishers. March of Dimes. (2012a). Chromosomal abnormalities. Available at http://www.marchofdimes.com/hbhb_syndication/15530_1209.asp –—. (2012b). Down syndrome. Available at http://www.marchofdimes .com/baby/birthdefects_downsyndrome.html –—. (2012c). Birth defects: What are they and how do they happen? [Online] Available at http://www.marchofdimes.com/baby/birthdefects.html –—. (2012d). How your baby grows. [Online] Available at http://www .marchofdimes.com/pregnancy/yourbody_babygrowth.html –—. (2012e). Routine prenatal tests. [Online] Available at http://www .marchofdimes.com/pregnancy/prenatalcare_routinetests.html —–. (2011). Core curriculum for maternal-newborn nursing (4th ed.). St. Louis: Saunders Elsevier. MedlinePlus. (2012). Prenatal testing [Online] Available at http://www .nlm.nih.gov/medlineplus/prenataltesting.html Moore, K. L., Persaud, T. V. N., & Torchia, M. G. (2011). The developing human (9th ed.). Philadelphia, PA: Saunders Elsevier Health Sciences. Mujezinovic, F., Prosnik, A., & Alfirevic, Z. (2010). Different communication strategies for disclosing results of diagnostic prenatal testing. Cochrane Database of Systematic Reviews 2010, Issue 11. Art. No.: CD007750. DOI: 10.1002/14651858.CD007750.pub2. Nakata, N., Wang, Y., & Bhatt, S. (2010). Trends in prenatal screening and diagnostic testing among women referred for advanced maternal age. Prenatal Diagnosis, 30(3), 198–206. National Organization for Rare Disorders [NORD]. (2011a). Trisomy 18 syndrome. Available at http://www.rarediseases.org/search/rdbdetail_abstract.html?disname=Trisomy%2018%20Syndrome –—. (2011b). Trisomy 13 syndrome. Available at http://www.rarediseases.org/search/rdbdetail_abstract.html?disname=Trisomy%20 13%20Syndrome –—. (2011c). Cri du chat syndrome. Available at http://www.rarediseases.org/search/rdbdetail_abstract.html?disname=Cri%20du%20 Chat%20Syndrome

–—. (2011d). Fragile X syndrome. Available at http://www.rarediseases.org/search/rdbdetail_abstract.html?disname=Fragile%20X%20 Syndrome –—. (2011e) Turner syndrome. Available at http://www.rarediseases .org/search/rdbdetail_abstract.html?disname=Turner%20Syndrome –—. (2011f). Klinefelter syndrome. Available at http://www.rarediseases.org/search/rdbdetail_abstract.html?disname=Klinefelter%20 Syndrome Pasca, A. M., & Penn, A. A. (2010). The placenta: The lost neuroendocrine organ. NeoReviews, 11(2), 64–74. Polin, R. A., Fox, W. W., & Abman, S. H. (2011). Fetal and neonatal physiology (4th ed.). St. Louis: Saunders Elsevier. Postellon, D. (2011). Turner syndrome. eMedicine. Available at http:// emedicine.medscape.com/article/949681-overview Rand, C. (2010). DNA and heredity. Mankato, MN: Heinemann-Raintree Publishers. Scott, D.A. & Lee, B. (2011). Chapter 75: Patterns of Genetic Transmission. In R. M. Kliegman, B. F. Stanton, J.W. St. Geme, N.F. Schor, & R.E. Behrman, (Eds.), Nelson’s textbook of pediatrics (19th ed., p. 383–94). Philadelphia: Saunders. Saravelos, S. H., & Regan, L. (2011). The importance of preconception counseling and early pregnancy monitoring. Seminars in Reproductive Medicine, 29(6), 557–568. Stables, D., & Rankin, J. (2010). Physiology in childbearing (3rd ed.). Oxford, UK: Elsevier Health Sciences Tamura, T., Kanuma, T., Nakazato, T., Faried, L., Aoki, H., & Minegishi, T. (2010). A new system for regulated functional gene expression for gene therapy applications: Nuclear delivery of a p16INK4Aestrogen receptor carboxy terminal fusion protein only in the presence of estrogen. International Journal of Oncology, 36(4), 905–912. Twisk, M., Mastenbroek, S., van Wely, M., Heineman, M. J., Van der Veen, F., & Repping, S. (2011). Preimplantation genetic screening for abnormal number of chromosomes (aneuploidies) in in vitro fertilization or intracytoplasmic sperm injection. Cochrane Database of Systematic Reviews, Issue 2. Art. No.: CD005291. DOI:10.1002/14651858. CD005291.pub2. U.S. Department of Energy Genome Programs. (2010). Human Genome Project information: Gene testing (http://genomics.energy.gov). Retrieved March 5, 2012, from http://www.ornl.gov/sci/techresources/ Human_Genome/medicine/genetest.shtml –—. (2011a). Human Genome Project information: Gene therapy (http://genomics.energy.gov). Retrieved March 5, 2012, from http:// www.ornl.gov/sci/techresources/Human_Genome/medicine/ genetherapy.shtml –—. (2011b). Human Genome Project information (http://genomics .energy.gov). Retrieved March 5, 2012, from http://www.ornl.gov/ sci/techresources/Human_Genome/home.shtml –—. (2011c). Human Genome Project information: Ethical, legal, and social issues research. Retrieved March 5, 2012, from http://www .ornl.gov/sci/techresources/Human_Genome/research/elsi.shtml. Van Leeuwen, A. M., Poelhuis-Leth, D., & Bladh, M. L. (2011). Davis’s comprehensive handbook of laboratory & diagnostic tests with nursing implications (4th ed.). Philadelphia, PA: F.A. Davis Company. Verklan, M. T., & Walden, M. (2010). Core curriculum for neonatal ­intensive care nursing (4th ed.). St. Louis: Saunders Elversier. Zhang, Z., & Yu, J. (2011). On the organizational dynamics of the ­genetic code. Genomics, Proteomics & Bioinformatics. 9(1-2), 21–29.

CHAPTER W O R K S H E E T MULTIPLE-CHOICE QUESTIONS

CRITICAL THINKING EXERCISE

1. After teaching a group of students about fertilization, the instructor determines that the teaching was successful when the group identifies which as the usual site of fertilization? a. Fundus of the uterus b. Endometrium of the uterus c. Distal portion of fallopian tube d. Follicular tissue of the ovary

1. Mr. and Mrs. Martin wish to start a family, but they can’t agree on something important. Mr. Martin wants his wife to be tested for cystic fibrosis (CF) to see if she is a carrier. Mr. Martin had a brother with CF and watched his parents struggle with the hardship and the expense of caring for him for years, and he doesn’t want to experience it in his own life. Mr. Martin has found out he is a CF carrier. Mrs. Martin doesn’t want to have the test because she figures that once a baby is in their arms, they will be glad, no matter what. a. What information/education should this couple consider before deciding whether to have the test? b. How can you assist this couple in their decisionmaking process? c. What is your role in this situation if you don’t agree with their decision?

2. A client comes to the clinic for pregnancy testing. The nurse explains that the test detects the presence of which hormone? a. hPL b. hCG c. FSH d. TSH 3. The nurse is counseling a couple, one of whom is affected by an autosomal dominant disorder. They express concerns about the risk of transmitting the disorder. What is the best response by the nurse regarding the risk that their baby may have for the disease? a. “You have a one in four (25%) chance.” b. “The risk is 12.5%, or a one in eight chance.” c. “The chance is 100%.” d. “Your risk is 50%, or a one in two chance.” 4. What is the first step in determining a couple’s risk for a genetic disorder? a. Observing the client and family over time b. Conducting extensive psychological testing c. Obtaining a thorough family health history d. Completing an extensive exclusionary list 5. A nurse is working in a women’s health clinic. Genetic counseling would be most appropriate for the woman who: a. Just had her first miscarriage at 10 weeks b. Is 30 years old and planning to conceive c. Has a history that reveals a close relative with Down syndrome d. Is 18 weeks pregnant with a normal triple screen result

STUDY ACTIVITIES 1. Obtain the video Miracle of Life, which shows conception and fetal development. What are your impressions? Is the title of this video realistic? 2. Select one of the websites listed in to explore the topic of genetics. Critique the information presented. Was it understandable to a layperson? What specifically did you learn? Share your findings with your classmates during a discussion group. 3. Draw your own family pedigree, identifying inheritance patterns. Share it with your family to validate its accuracy. What did you discover about your family’s past health? 4. Select one of the various prenatal screening tests (alpha-fetoprotein, amniocentesis, chorionic villus sampling, or fetal nuchal translucency) and research it in depth. Role-play with another nursing student how you would explain its purpose, the procedure, and potential findings to an expectant couple at risk for a fetal abnormality.

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11 KEY TERMS ballottement Braxton Hicks contractions Chadwick’s sign dietary reference intakes (DRIs) Goodell’s sign Hegar’s sign linea nigra physiologic anemia of pregnancy pica quickening trimester

Maternal Adaptation During Pregnancy Learning Objectives Upon completion of the chapter, you will be able to: 1. Define the key terms used in this chapter. 2. Differentiate between subjective (presumptive), objective (probable), and diagnostic (positive) signs of pregnancy. 3. Appraise maternal physiologic changes that occur during pregnancy. 4. Summarize the nutritional needs of the pregnant woman and her fetus. 5. Characterize the emotional and psychological changes that occur during pregnancy.

Marva, age 17, appeared at the health department clinic complaining that she had a stomach virus and needed to be seen today. When the nurse asked her additional questions about her illness, Marva reported that she had been sick to her stomach and “beat tired” for days. She had stopped eating to avoid any more nausea and vomiting.

WOW

Words of Wisdom

When a woman discovers that she is pregnant, she must remember to protect and nourish the fetus by making wise choices.



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Pregnancy is a normal life event that involves considerable physical and psychological adjustments for the mother. A pregnancy is divided into three trimesters of 13 weeks each (Tharpe, Farley & Jordan, 2013). Within each trimester, numerous adaptations take place that facilitate the growth of the fetus. The most obvious are physical changes to accommodate the growing fetus, but pregnant women also undergo psychological changes as they prepare for parenthood.

SIGNS AND SYMPTOMS OF PREGNANCY Traditionally, signs and symptoms of pregnancy have been grouped into the following categories: presumptive, probable, and positive (Box 11.1). The only signs that can determine a pregnancy with 100% accuracy are positive signs.

What additional information is necessary to ­complete the assessment of Marva, the 17-year-old with nausea and vomiting? What diagnostic tests might be done to confirm the nurse’s suspicion that she is pregnant?

J

Consider This

im and I decided to start our family, so I stopped taking the pill 3 months ago. One morning when I got out of bed to take the dog out, I felt queasy and light-headed. I sure hoped I wasn’t coming down with the flu. By the end of the week, I was feeling really tired and started taking naps in the afternoon. In addition, I seemed to be going to the bathroom frequently, despite not drinking much fluid. When my breasts started to tingle and ache, I decided to make an appointment with my doctor to see what “illness” I had contracted. After listening to my list of physical complaints, the office nurse asked me if I might be pregnant. My eyes opened wide: I had somehow missed the link between my symptoms and pregnancy. I started to think about when my last period was, and it had been 2 months ago. The office ran a pregnancy test and much to my surprise it was positive! Thoughts: Many women stop contraceptives in an attempt to achieve pregnancy but miss the early signs of pregnancy. This woman was experiencing several signs of early pregnancy—urinary frequency, fatigue, morning nausea, and breast tenderness. What advice can the nurse give this woman to ease these symptoms? What additional education related to her pregnancy would be appropriate at this time?

Subjective (Presumptive) Signs Presumptive signs are those signs that the mother can perceive. The most obvious presumptive sign of pregnancy is the absence of menstruation. Skipping a period is not a reliable sign of pregnancy by itself, but if it is accompanied by consistent nausea, fatigue, breast tenderness, and urinary frequency, pregnancy would seem very likely.

Presumptive changes are the least reliable indicators of pregnancy because any one of them can be caused by conditions other than pregnancy (Shields, 2012). For example, amenorrhea can be caused by early menopause, endocrine dysfunction, malnutrition, anemia, diabetes mellitus, long-distance running, cancer, or stress. Nausea

BOX 11.1

SIGNS AND SYMPTOMS OF PREGNANCY Presumptive (Time of Occurrence) Probable (Time of Occurrence) Fatigue (12 wks) Breast tenderness (3–4 wks) Nausea and vomiting (4–14 wks) Amenorrhea (4 wks) Urinary frequency (6–12 wks) Hyperpigmentation of the skin (16 wks) Fetal movements (quickening; 16–20 wks) Uterine enlargement (7–12 wks) Breast enlargement (6 wks)

Braxton Hicks contractions (16–28 wks) Positive pregnancy test (4–12 wks) Abdominal enlargement (14 wks) Ballottement (16–28 wks) Goodell’s sign (5 wks) Chadwick’s sign (6–8 wks) Hegar’s sign (6–12 wks)

Positive (Time of Occurrence) Ultrasound verification of ­embryo or fetus (4–6 wks) Fetal movement felt by ­experienced clinician (20 wks) Auscultation of fetal heart tones via Doppler (10–12 wks)

Adapted from Bope, E. T., & Kellerman, R. D. (2012). Conn’s current therapy 2012. Philadelphia, PA: Saunders Elsevier; Shields, A. D. (2012). P ­ regnancy diagnosis. eMedicine. Retrieved from http://emedicine.medscape.com/article/262591-overview; and Simpson, K. R., & Creehan, P. A. (2011). AWHONN’s perinatal nursing (3rd ed.). Philadelphia, PA: Lippincott Williams & Wilkins.

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and vomiting can be caused by gastrointestinal disorders, food poisoning, acute infections, or eating disorders. Fatigue could be caused by anemia, stress, or viral infections. Breast tenderness may result from chronic cystic mastitis, premenstrual changes, or the use of oral contraceptives. Urinary frequency could have a variety of causes other than pregnancy, such as infection, cystocele, structural disorders, pelvic tumors, or emotional tension (Tharpe, Farley, & Jordan, 2013).

Objective (Probable) Signs Probable signs of pregnancy are those that can be detected on physical examination by a health care professional. Common probable signs of pregnancy include softening of the lower uterine segment or isthmus (Hegar’s sign), softening of the cervix (Goodell’s sign), and a bluish-purple coloration of the vaginal mucosa and cervix (Chadwick’s sign). Other probable signs include changes in the shape and size of the uterus, abdominal enlargement, Braxton Hicks contractions, and ballottement (the examiner pushes against the woman’s cervix during a pelvic examination and feels a rebound from the floating fetus). Along with these physical signs, pregnancy tests are also considered a probable sign of pregnancy. In-home pregnancy testing became available in the United States in late 1977. In-home testing appeals to the general public because of convenience, cost, and confidentiality. Several pregnancy tests are available (Table 11.1). The tests vary in sensitivity, specificity, and accuracy and are influenced by the length of gestation, specimen concentration, presence of blood, and the presence of some drugs. Human chorionic gonadotropin (hCG) is detectable in the serum of approximately 5% of clients 8  days after conception and in more than 98% of clients by day 11 (Shields, 2012). At least 25 different home pregnancy

tests are currently marketed in the United States. Most of these tests claim “99% accuracy” according to a U.S. Food and Drug Administration (FDA) guideline or make other similar statements on the packaging or product insert. The 99% accuracy statement in reference to the FDA guideline is misleading in that it has no bearing on the ability of the home pregnancy test to detect early pregnancy (Shields, 2012). The limitations of these tests must be understood so that pregnancy detection is not delayed significantly. Early pregnancy detection allows for the commencement of prenatal care, potential medication changes, and lifestyle changes to promote a healthy pregnancy. hCG is a glycoprotein and the earliest biochemical marker for pregnancy. Many pregnancy tests are based on the recognition of hCG or a beta subunit of hCG. hCG levels in normal pregnancy usually double every 48 to 72  hours until they peak approximately 60 to 70 days after fertilization. At this point, they decrease to a ­plateau at 100 to 130 days of pregnancy. The hCG doubling time has been used as a marker by clinicians to differentiate normal from abnormal gestations. Low ­ levels are associated with an ectopic pregnancy and higher-than-normal levels may indicate a molar pregnancy or multiple-­ gestational pregnancies (Levin, ­Hopkins, & ­Tiffany, 2011).

Take Note! T his elevation of hCG corresponds to the morning ­sickness period of approximately 6 to 12 weeks during early pregnancy. Although probable signs suggest pregnancy and are more reliable than presumptive signs, they still are not 100% reliable in confirming a pregnancy. For example, uterine tumors, polyps, infection, and pelvic congestion can cause changes to uterine shape, size, and consistency.

TABLE 11.1

SELECTED PREGNANCY TESTS

Type

Specimen

Example

Remarks

Agglutination i­ nhibition tests

Urine

Pregnosticon, Gravindex

If hCG is present in urine, agglutination does not occur, which is positive for pregnancy; reliable 14–21 days after conception; 95% accurate in diagnosing pregnancy

Immunoradiometric assay

Blood serum

Neocept, Pregnosis

Measures ability of blood sample to inhibit the binding of radiolabeled hCG to receptors; reliable 6–8 days after ­conception; 99% accurate in diagnosing pregnancy

Enzyme-linked immunosorbent assay (ELISA)

Blood serum or urine

Over-the-counter home/office pregnancy tests; precise

Uses an enzyme to bond with hCG in the urine if present; ­reliable 4 days after implantation; 99% accurate if hCG specific

Adapted from Hackley, B., Kriebs, J. M., & Rousseau, M. E. (2010). Primary care of women: A guide for midwives and women’s health providers (2nd ed.). Sudbury, MA: Jones & Bartlett; and Shields, A. D. (2012). Pregnancy diagnosis. eMedicine. Retrieved from http://emedicine.medscape.com/ article/262591-overview.



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And although pregnancy tests are used to establish the diagnosis of pregnancy when the physical signs are still inconclusive, they are not completely reliable, because conditions other than pregnancy (e.g., ovarian cancer, choriocarcinoma, hydatidiform mole) can also elevate hCG levels.

Positive Signs Usually within 2  weeks after a missed period, enough subjective symptoms are present so that a woman can be reasonably sure she is pregnant. However, an experienced health care professional can confirm her suspicions by identifying positive signs of pregnancy that can be directly attributed to the fetus. The positive signs of pregnancy confirm that a fetus is growing in the uterus. Visualizing the fetus by ultrasound, palpating for fetal movements, and hearing a fetal heartbeat are all signs that make the pregnancy a certainty. Once pregnancy has been confirmed, the health care professional will set up a schedule of prenatal visits to assess the woman and her fetus throughout the entire pregnancy. Assessment and education begins at the first visits and continues throughout the pregnancy (see Chapter 12).

Remember Marva, who thought she had a stomach virus? Her pregnancy test was positive. On questioning by the nurse, she acknowledged missing two menstrual periods and being sexually active with her boyfriend without using protection. What is the nurse’s role at this point with Marva? What instructions might be given to her while she waits for her first prenatal visit?

PHYSIOLOGIC ADAPTATIONS DURING PREGNANCY Every system of a woman’s body changes during pregnancy to accommodate the needs of the growing fetus, and these changes occur with startling rapidity. The physical changes of pregnancy can be uncomfortable, although every woman reacts uniquely.

Reproductive System Adaptations Significant changes occur throughout the woman’s body during pregnancy to accommodate the growing human being within her. Many have a protective role for maternal

homeostasis and are essential to meet the demands of both the mother and the fetus. Many adaptations are reversible after the woman gives birth, but some persist for life.

Uterus During the first few months of pregnancy, estrogen stimulates uterine growth, and the uterus undergoes a tremendous increase in size, weight, length, width, depth, volume, and overall capacity throughout pregnancy. The weight of the uterus increases from 70  g to about 1,100 to 1,200 g at term; its capacity increases from 10 to 5,000 mL or more at term (Cunningham et al., 2010). The uterine walls thin to 1.5 cm or less; from a solid globe, the uterus becomes a hollow vessel. Uterine growth occurs as a result of both hyperplasia and hypertrophy of the myometrial cells, which do not increase much in number but do increase in size. In early pregnancy, uterine growth is due to hyperplasia of uterine smooth muscle cells within the myometrium; however, the major component of myometrial growth occurs after mid-gestation due to smooth muscle cell hypertrophy caused by mechanical stretch of uterine tissue by the growing fetus (Shynlova, Kwong, & Lye, 2010). Blood vessels elongate, enlarge, dilate, and sprout new branches to support and nourish the growing muscle tissue, and the increase in uterine weight is accompanied by a large increase in uterine blood flow, which is necessary to perfuse the uterine muscle and accommodate the growing fetus. As pregnancy progresses, 80% to 90% of uterine blood flow goes to the placenta, with the remainder distributed between the endometrium and myometrium. During pregnancy, the diameter of the main uterine artery approximately doubles in size. This enlargement from a narrow to a larger-caliber vessel enhances the capacity of the uteroplacental vessels to accommodate the increased blood volume needed to supply the placenta (Blackburn, 2012). Uterine contractility is enhanced as well. Spontaneous, irregular, and painless contractions, called Braxton Hicks contractions, begin during the first trimester. These contractions continue throughout pregnancy, becoming especially noticeable during the last month, when they function to thin out or efface the cervix before birth (see Chapter 12 for more information). The lower portion of the uterus (the isthmus) does not undergo hypertrophy and becomes increasingly thinner as pregnancy progresses, thereby forming the lower uterine segment Changes in the lower uterus occurring during the first 6 to 8 weeks of gestation produce some of the typical findings, including a positive Hegar’s sign. This softening and compressibility of the lower uterine segment results in exaggerated uterine anteflexion during the early months of pregnancy, which adds to urinary frequency (Brosens et al., 2010).

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Liver pushed up Stomach compressed

Supine position

Side-lying position

FIGURE 11.2 Supine hypotensive syndrome.

uterus in centimeters, which corresponds to the number of gestational weeks, is commonly used to date the pregnancy.

Take Note!

Bladder compressed

FIGURE 11.1 The growing uterus in the abdomen.

The uterus remains in the pelvic cavity for the first 3  months of pregnancy, after which it progressively ascends into the abdomen (Fig.  11.1). As the uterus grows, it presses on the urinary bladder and causes the increased frequency of urination experienced during early pregnancy. In addition, the heavy gravid uterus in the last trimester can fall back against the inferior vena cava in the supine position, resulting in vena cava compression, which reduces venous return and decreases cardiac output and blood pressure, with increasing orthostatic stress. This occurs when the woman changes her position from recumbent to sitting to standing. This acute hemodynamic change, termed supine hypotensive syndrome, causes the woman to experience symptoms of weakness, lightheadedness, nausea, dizziness, or syncope (Fig. 11.2). These changes are reversed when the woman is in the side-lying position, which displaces the uterus to the left and off the vena cava. The uterus, which starts as a pear-shaped organ, becomes ovoid as length increases over width. By 20 weeks’ gestation, the fundus, or top of the uterus, is at the level of the umbilicus and measures 20 cm. A monthly measurement of the height of the top of the

Fundal height usually can be correlated with gestational weeks most accurately between 18 and 32 weeks. Obesity, hydramnios and uterine fibroids interfere with the accuracy of this correlation. The fundus reaches its highest level, at the xiphoid process, at approximately 36 weeks. Between 38 and 40 weeks, fundal height drops as the fetus begins to descend and engage into the pelvis. Because it pushes against the diaphragm, many women experience shortness of breath. By 40 weeks, the fetal head begins to descend and engage in the pelvis, which is termed lightening. For the woman who is pregnant for the first time, lightening usually occurs approximately 2 weeks before the onset of labor; for the woman who is experiencing her second or subsequent pregnancy, it usually occurs at the onset of labor. Although breathing becomes easier because of this descent, the pressure on the urinary bladder now increases and women experience urinary frequency again.

Cervix Between weeks 6 and 8 of pregnancy, the cervix begins to soften (Goodell’s sign) due to vasocongestion. Along with the softening, the endocervical glands increase in size and number and produce more cervical mucus. Under the influence of progesterone, a thick mucus plug is formed that blocks the cervical os and protects the opening from bacterial invasion. At about the same time, increased vascularization of the cervix causes Chadwick’s sign. Cervical ripening (softening, effacement, and increased distensibility) begins about 4 weeks before birth. The connective tissues of the cervix undergo biochemical modifications in preparation for labor that result in changes to its elasticity and strength. These changes are mediated through several factors, including inflammation, cervical stretch, pressure of the fetal presenting part,



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and release of hormones, including oxytocin, relaxin, nitric oxide, and prostaglandins (Dubicke et al., 2010).

Vagina During pregnancy, vascularity increases because of the influences of estrogen, resulting in pelvic congestion and hypertrophy of the vagina in preparation for the distention needed for birth. The vaginal mucosa thickens, the connective tissue begins to loosen, the smooth muscle begins to hypertrophy, and the vaginal vault begins to lengthen (Bope & Kellerman, 2012). Vaginal secretions become more acidic, white, and thick. Most women experience an increase in a whitish vaginal discharge, called leukorrhea, during pregnancy. This is normal except when it is accompanied by itching and irritation, possibly suggesting Candida albicans, a monilial vaginitis, which is a very common occurrence in this glycogen-rich environment (Gor, 2011). Symptomatic vulvovaginal candidiasis affects 15% of pregnant women (Babic & Hukic, 2010). It is a benign fungal condition that is uncomfortable for the woman and can be transmitted from an infected mother to her newborn at birth. Neonates develop an oral infection known as thrush, which presents as white patches on the mucous membranes of their mouths. It is self-limiting and is treated with local antifungal agents.

Ovaries The increased blood supply to the ovaries causes them to enlarge until approximately the 12th to 14th week of gestation. The ovaries are not palpable after that time because the uterus fills the pelvic cavity. Ovulation ceases during pregnancy because of the elevated levels of estrogen and progesterone, which block secretion of follicle-stimulating hormone (FSH) and luteinizing hormone (LH) from the anterior pituitary. The ovaries are very active in hormone production to support the pregnancy until about weeks 6 to 7, when the corpus luteum regresses and the placenta takes over the major production of progesterone.

Breasts The breasts increase in fullness, become tender, and grow larger throughout pregnancy under the influence of estrogen and progesterone. The breasts become highly vascular, and veins become visible under the skin. The nipples become larger and more erect. Both the nipples and the areola become deeply pigmented, and tubercles of Montgomery (sebaceous glands) become prominent. These sebaceous glands keep the nipples lubricated for breast-feeding. Changes that occur in the connective tissue of the breasts, along with the tremendous growth, lead to striae

(stretch marks) in approximately half of all pregnant women (Tharpe et al., 2013). Initially they appear as pink to purple lines on the skin, but they eventually fade to a silver color. Although they become less conspicuous in time, they never completely disappear. Creamy, yellowish breast fluid called colostrum can be expressed by the third trimester. This fluid provides nourishment for the breast-feeding newborn during the first few days of life (see Chapters 15 and 16 for more information). Table 11.2 summarizes reproductive system adaptations.

General Body System Adaptations In addition to changes in the reproductive system, the pregnant woman also experiences changes in virtually every other body system in response to the growing fetus.

Gastrointestinal System The gastrointestinal (GI) system begins in the oral cavity and ends at the rectum. During pregnancy, the gums become hyperemic, swollen, and friable and tend to bleed easily. This change is influenced by estrogen and increased proliferation of blood vessels and circulation to the mouth. In addition, the saliva produced in the mouth becomes more acidic. Some women complain about excessive salivation, termed ptyalism, which may be caused by the decrease in unconscious swallowing by the woman when nauseated (Cunningham et al., 2010). Dental plaque, calculus, and debris deposits increase during pregnancy and are all associated with gingivitis. An increased production of female hormones during pregnancy contributes to the development of gingivitis and periodontitis because vascular permeability and possible tissue edema are both increased. It is reported that as many as 50% to 70% of pregnant women will have some level of gingivitis during pregnancy as a result of hormonal changes that promote inflammation (Straka, 2011). Previous studies linked periodontal disease with preterm birth and low-birth-weight risk, but more recent research findings indicated no reduction in preterm births with the treatment of periodontal disease during pregnancy (Srinivas & Parry, 2012). Smooth muscle relaxation and decreased peristalsis occur related to the influence of progesterone. Elevated progesterone levels cause smooth muscle relaxation, which results in delayed gastric emptying and decreased peristalsis. Transition time of food throughout the GI tract may be so much slower that more water than normal is reabsorbed, leading to bloating and constipation. Constipation can also result from low-fiber food choices, reduced fluid intake, use of iron supplements, decreased activity level, and intestinal displacement secondary to a growing uterus. Constipation, increased venous pressure,

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TABLE 11.2

SUMMARY OF REPRODUCTIVE SYSTEM ADAPTATIONS

Reproductive Organ Adaptations Uterus

Size increases to 20 times that of nonpregnant size. Capacity increases by 2,000 times to accommodate the developing fetus. Weight increases from 2 oz to approximately 2 lb at term. Uterine growth occurs as a result of both hyperplasia and hypertrophy of the myometrial cells. Increased strength and elasticity allow uterus to contract and expel fetus during birth.

Cervix

Increases in mass, water content, and vascularization Changes from a relatively rigid to a soft, distensible structure that allows the fetus to be expelled Under the influence of progesterone, a thick mucus plug is formed, which blocks the cervical os and protects the developing fetus from bacterial invasion.

Vagina

Increased vascularity because of estrogen influences, resulting in pelvic congestion and hypertrophy Increased thickness of mucosa, along with an increase in vaginal secretions to prevent bacterial infections

Ovaries

Increased blood supply to the ovaries causes them to enlarge until approximately the 12th to 14th week of gestation. They actively produce hormones to support the pregnancy until weeks 6 to 7 when the placenta takes over the production of progesterone.

Breasts

Breast changes begin soon after conception; they increase in size and areolar pigmentation. The tubercles of Montgomery enlarge and become more prominent, and the nipples become more erect. The blood vessels become more prominent, and blood flow to the breast doubles.

and the pressure of the gravid uterus contribute to the formation of hemorrhoids. The slowed gastric emptying combined with relaxation of the cardiac sphincter allows reflux, which causes heartburn. Acid indigestion or heartburn (pyrosis) seems to be a universal problem for pregnant women. It is caused by regurgitation of the stomach contents into the upper esophagus and may be associated with the generalized relaxation of the entire digestive system. Overthe-counter antacids will usually relieve the symptoms, but they should be taken with the health care provider’s knowledge and only as directed. The emptying time of the gallbladder is prolonged secondary to the smooth muscle relaxation from progesterone. Hypercholesterolemia can follow, increasing the risk of gallstone formation. Other risk factors for gallbladder disease include obesity, Hispanic ethnicity, and ­increasing maternal age (Stinton & Shaffer, 2012). Nausea and vomiting, better known as morning sickness, plague about 80% of pregnant women (Singh, 2012). Although it occurs most often in the morning, the nauseated feeling can last all day in some women. The

highest incidence of morning sickness occurs between 6 and 12 weeks. The physiologic basis for morning sickness is still debatable. It has been linked to the high levels of hCG, high levels of circulating estrogens, prostaglandins, reduced stomach acidity, advancing maternal age, and the lowered tone and motility of the digestive tract (Chan et al., 2011).

Cardiovascular System Cardiovascular changes occur early during pregnancy to meet the demands of the enlarging uterus and the placenta for more blood and more oxygen. Perhaps the most striking cardiac alteration occurring during pregnancy is the increase in blood volume. BLOOD VOLUME Blood volume increases by approximately 1,500 mL, or 50% above nonpregnant levels, by the 30th week of gestation, and remains more or less constant thereafter (Cunningham et al., 2010). The increase is made up of 1,000 mL plasma plus 450 mL red blood cells (RBCs). It



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begins at weeks 10 to 12, peaks at weeks 32 to 34, and decreases slightly by week 40.

Take Note! The rise in blood volume correlates directly with fetal weight. This increase in blood volume is needed to provide adequate hydration of fetal and maternal tissues, to supply blood flow to perfuse the enlarging uterus, and to provide a reserve to compensate for blood loss at birth and during postpartum (Hornstein & Schwein, 2012). This increase is also necessary to meet the increased metabolic needs of the mother and to meet the need for increased perfusion of other organs, especially the woman’s kidneys, because she is excreting waste products for herself and the fetus. CARDIAC OUTPUT AND HEART RATE Cardiac output, the product of stroke volume and heart rate, is a measure of the functional capacity of the heart. It increases from 30% to 50% over the nonpregnant rate by the 32nd week of pregnancy and declines to about a 20% increase at 40 weeks’ gestation. The increase in cardiac output is associated with an increase in venous return and greater right ventricular output, especially in the left lateral position (Bope & Kellerman, 2012). Heart rate increases by 10 to 15 bpm between 14 and 20 weeks of gestation, and this persists to term. There is slight hypertrophy or enlargement of the heart during pregnancy. This is probably to accommodate the increase in blood volume and cardiac output. The heart works harder and pumps more blood to supply the oxygen needs of the fetus as well as those of the mother. Both heart rate and venous return are increased in pregnancy, contributing to the increase in cardiac output seen throughout gestation. A woman with preexisting heart disease may become symptomatic and begin to decompensate during the time the blood volume peaks. Close monitoring is warranted during 28 to 35 weeks’ gestation. BLOOD PRESSURE Blood pressure, especially the diastolic pressure, declines slightly during pregnancy as a result of peripheral vasodilation caused by progesterone. It usually reaches a low point at mid-pregnancy and thereafter increases to prepregnant levels until term. During the first trimester, blood pressure typically remains at the prepregnancy level. During the second trimester, the blood pressure decreases 5 to 10 mm Hg and thereafter returns to first-trimester levels (Nama, Antonios, Onwude, & Manyonda, 2011). Any significant rise in blood pressure during pregnancy should be investigated to rule out gestational hypertension. BLOOD COMPONENTS The number of RBCs also increases throughout pregnancy to a level 25% to 33% higher than nonpregnant

values, depending on the amount of iron available. This increase is necessary to transport the additional oxygen required during pregnancy. Although there is an increase in RBCs, there is a greater increase in the plasma volume as a result of hormonal factors and sodium and water retention. Because the plasma increase exceeds the increase of RBC production, normal hemoglobin and hematocrit values decrease. This state of hemodilution is referred to as physiologic anemia of pregnancy. Changes in RBC volume are due to increased circulating erythropoietin and accelerated RBC production. The rise in erythropoietin in the last two trimesters is stimulated by progesterone, prolactin, and human placental lactogen (Sheppard & Khalil, 2010). Iron requirements during pregnancy increase because of the demands of the growing fetus and the increase in maternal blood volume. The fetal tissues prevail over the mother’s tissues with respect to use of iron stores. With the accelerated production of RBCs, iron is necessary for hemoglobin formation, the oxygen-­ carrying component of RBCs.

Take Note!  any women enter pregnancy with insufficient iron M stores and thus need supplementation to meet the extra demands of pregnancy. Both fibrin and plasma fibrinogen levels increase, along with various blood-clotting factors. These factors make pregnancy a hypercoagulable state. These changes, coupled with venous stasis secondary to venous pooling, which occurs during late pregnancy after long periods of standing in the upright position with the pressure exerted by the uterus on the large pelvic veins, contribute to slowed venous return, pooling, and dependent edema. These factors also increase the woman’s risk for venous thrombosis (O’Connor et al., 2011).

Respiratory System The growing uterus and the increased production of the hormone progesterone cause the lungs to function differently during pregnancy. During pregnancy, the amount of space available to house the lungs decreases as the uterus puts pressure on the diaphragm and causes it to shift upward by 4  cm above its usual position. The growing uterus does change the size and shape of the thoracic cavity, but diaphragmatic excursion increases, chest circumference increases by 2 to 3 inches, and the transverse diameter increases by an inch, allowing a larger tidal volume, as evidenced by deeper breathing (Blackburn, 2012). Tidal volume, or the volume of air inhaled, increases by 40% (from 500 to 700 mL) as the pregnancy progresses. This increase results in maternal hyperventilation and hypocapnia. As a result of these changes, the woman’s breathing becomes more diaphragmatic than abdominal. Concomitant with the increase in

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tidal volume is a 20% to 40% increase in maternal oxygen consumption due to the increased oxygen requirements of the developing fetus, placenta, and maternal organs. Anatomic and physiologic changes of pregnancy predispose the mother to increased morbidity and mortality and increase the risks of a less than optimal outcome for the fetus. The frequency and significance of acute and chronic respiratory conditions in pregnant women have increased in recent years. Because of these various changes, pregnant women with asthma, pneumonia, or other respiratory pathology are more susceptible to early decompensation (Frye, Clark, Piacenza, & Shay-Zapien, 2011). A pregnant woman breathes faster and more deeply because she and the fetus need more oxygen. Oxygen consumption increases during pregnancy even as airway resistance and lung compliance remain unchanged. Changes in the structures of the respiratory system take place to prepare the body for the enlarging uterus and increased lung volume (Blackburn, 2012). As muscles and cartilage in the thoracic region relax, the chest broadens, with a conversion from abdominal breathing to thoracic breathing. This leads to a 50% increase in air volume per minute. All of these structural alterations are temporary and revert back to their prepregnant state at the end of the pregnancy. Increased vascularity of the respiratory tract is influenced by increased estrogen levels, leading to congestion. Rising levels of sex hormones and heightened sensitivity to allergens may influence the nasal mucosa, precipitating epistaxis (nosebleed) and rhinitis. This congestion gives rise to nasal and sinus stuffiness and changes in the tone and quality of the woman’s voice (Kumar, Hayhurst, & Robson, 2011).

Renal/Urinary System The renal system must handle the effects of increased maternal intravascular and extracellular volume and metabolic waste products as well as excretion of fetal wastes. The predominant structural change in the renal system during pregnancy is dilation of the renal pelvis and uterus. Changes in renal structure occur as a result of the hormonal influences of estrogen and progesterone, pressure from an enlarging uterus, and an increase in maternal blood volume. Like the heart, the kidneys work harder throughout the pregnancy. Changes in kidney function occur to accommodate a heavier workload while maintaining a stable electrolyte balance and blood pressure. As more blood flows to the kidneys, the glomerular filtration rate (GFR) increases, leading to an increase in urine flow and volume, substances delivered to the kidneys, and filtration and excretion of water and solutes (Cunningham et al., 2010). Anatomically, the kidneys enlarge during pregnancy. Each kidney increases in length and weight as a result of hormonal effects that cause increased tone and decreased

motility of the smooth muscle. The renal pelvis becomes dilated. The ureters (especially the right ureter) elongate, widen, and become more curved above the pelvic rim as early as the 10th gestational week (Baum, 2010). Progesterone is thought to cause both of these changes because of its relaxing influence on smooth muscle. Blood flow to the kidneys increases by 50% to 80% as a result of the increase in cardiac output. This in turn leads to an increase in the GFR by as much as 40% to 60% starting during the second trimester. This elevation continues until birth (Krane, 2011). The activity of the kidneys normally increases when a person lies down and decreases on standing. This difference is amplified during pregnancy, which is one reason a pregnant woman feels the need to urinate frequently while trying to sleep. Late in the pregnancy, the increase in kidney activity is even greater when the woman lies on her side rather than her back. Lying on the side relieves the pressure that the enlarged uterus puts on the vena cava carrying blood from the legs. Subsequently, venous return to the heart increases, leading to increased cardiac output. Increased cardiac output results in increased renal perfusion and glomerular filtration. As a rule, all the physiologic changes maximize by the end of the second trimester and then start to return to the prepregnant level. However, changes in the anatomy take up to 3 months postpartum to subside (Krane, 2011).

Musculoskeletal System Changes in the musculoskeletal system are progressive, resulting from the influence of hormones, fetal growth, and maternal weight gain. Pregnancy is characterized by changes in posture and gait. By the 10th to 12th week of pregnancy, the ligaments that hold the sacroiliac joints and the pubis symphysis in place begin to soften and stretch, and the articulations between the joints widen and become more movable (Bope & Kellerman, 2012). The relaxation of the joints peaks by the beginning of the third trimester. The purpose of these changes is to increase the size of the pelvic cavity and to make delivery easier. The postural changes of pregnancy—an increased swayback and an upper spine extension to compensate for the enlarging abdomen—coupled with the loosening of the sacroiliac joints may result in lower back pain. The woman’s center of gravity shifts forward, requiring a realignment of the spinal curvatures. Factors thought to contribute to these postural changes include the alteration to the center of gravity that come with pregnancy, the influence of the pregnancy-related hormone relaxin on the pelvic joints, and the increasing weight and position of the growing fetus. An increase in the normal lumbosacral curve (lordosis) occurs and a compensatory curvature in the cervicodorsal area develops to assist her in maintaining her balance (Fig. 11.3). In addition, relaxation and



A

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B

increased mobility of joints occur because of the hormones progesterone and relaxin, which lead to the characteristic “waddle gait” that pregnant women demonstrate toward term. Increased weight gain can add to this discomfort by accentuating the lumbar and dorsal curves (Cumisky, 2011).

Integumentary System The skin of pregnant women undergoes hyperpigmentation primarily as a result of estrogen, progesterone, and melanocyte-stimulating hormone levels. These changes are mainly seen on the nipples, areola, umbilicus, perineum, and axilla. Although many integumentary changes disappear after giving birth, some only fade. Many pregnant women express concern about stretch marks, skin color changes, and hair loss. Unfortunately, little is known about how to avoid these changes. Complexion changes are not unusual. The increased pigmentation that occurs on the breasts and genitalia also develops on the face to form the “mask of pregnancy,” which is also called facial melasma or chloasma. It occurs in up to 70% of pregnant women. There is a genetic predisposition toward melasma, which is exacerbated by the sun, and it tends to recur in subsequent pregnancies. This blotchy, brownish pigment covers the forehead and cheeks in dark-haired women. Most facial pigmentation fade as the hormones subside at the end of the pregnancy, but some may linger. The skin in the middle of the abdomen may develop a pigmented line called linea nigra, which extends from the umbilicus to the pubic area (Fig. 11.4).

FIGURE 11.3 Postural changes during (A) the first trimester and (B) the third trimester.

Striae gravidarum, or stretch marks, are irregular reddish streaks that appear on the abdomen, breasts, and buttocks in about half of pregnant women. Striae are most prominent by 6 to 7 months. They result from reduced connective tissue strength resulting from the elevated adrenal steroid levels and stretching of the structures secondary to growth (Beard & Millington, 2012). They are more common in younger women, women with larger infants, and women with higher body mass

FIGURE 11.4 Linea nigra.

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indices. Nonwhites and women with a history of breast or thigh striae or a family history of striae gravidarum also are at higher risk. Several creams and lotions such as cocoa butter have been touted as being able to prevent striae gravidarum, but a recent study by Buchanan, Fletcher, & Reid (2010) found that cocoa butter does not prevent them. Vascular changes during pregnancy manifested in the integumentary system include varicosities of the legs, vulva, and perineum. Varicose veins commonly are the result of distention, instability, and poor circulation secondary to prolonged standing or sitting and the heavy gravid uterus placing pressure on the pelvic veins, preventing complete venous return. Interventions to reduce the risk of developing varicosities include: • Elevating both legs when sitting or lying down • Avoiding prolonged standing or sitting; changing position frequently • Resting in the left lateral position • Walking daily for exercise • Avoiding tight clothing or knee-high hosiery • Wearing support hose if varicosities are a preexisting condition to pregnancy Another skin manifestation, believed to be secondary to vascular changes and high estrogen levels, is the appearance of small blood vessels called vascular spiders. They may appear on the neck, thorax, face, and arms. They are especially obvious in white women and typically disappear after childbirth. Palmar erythema is a well-delineated pinkish area on the palmar surface of the hands. This integumentary change is also related to elevated estrogen levels (Trupin, 2011). Some women also notice a decline in hair growth during pregnancy. The hair follicles normally undergo a growing and resting phase. The resting phase is followed by a loss of hair; the hairs are then replaced by new ones. During pregnancy, fewer hair follicles go into the resting phase. After delivery, the body catches up with subsequent hair loss for several months. Nails typically grow faster during pregnancy. Pregnant women may experience increased brittleness, distal separation of the nail bed, whitish discoloration, and transverse grooves on the nails, but most of these conditions resolve in the postpartum period (Blackburn, 2012).

Endocrine System The endocrine system undergoes many changes during pregnancy because hormonal changes are essential in meeting the needs of the growing fetus. Hormonal changes play a major role in controlling the supplies of maternal glucose, amino acids, and lipids to the fetus. Although estrogen and progesterone are the main hormones involved in pregnancy changes, other endocrine glands and hormones also change during pregnancy.

THYROID GLAND The thyroid gland enlarges slightly and becomes more active during pregnancy as a result of increased vascularity and hyperplasia. Increased gland activity results in an increase in thyroid hormone secretion starting during the first trimester; levels taper off within a few weeks after birth and return to normal limits. Maternal thyroid hormone is transferred to the fetus beginning soon after conception and is critical for fetal brain development, neurogenesis, and organizational processes prior to 20  weeks when fetal thyroid production is low. However, even after the fetal thyroid is producing increasing amounts of hormone, much of the thyroxin (T4) needed for development continues to be provided by the mother. Low maternal thyroid levels with thyroid insufficiency, hypothyroidism, or low or inadequate iodine intake may compromise fetal neurologic development (Blackburn, 2012). With an increase in the secretion of thyroid hormones, the basal metabolic rate (BMR; the amount of oxygen consumed by the body over a unit of time in milliliters per minute) progressively increases by 25%, along with heart rate and cardiac output (Blackburn, 2012). PITUITARY GLAND The pituitary gland, also known as the hypophysis, is a small, oval gland about the size of a pea that is connected to the hypothalamus by a stalk called the infundibulum. During pregnancy, the pituitary gland enlarges; it returns to normal size after birth. The anterior lobe of the pituitary is glandular tissue and produces multiple hormones. The release of these hormones is regulated by releasing and inhibiting hormones produced by the hypothalamus. Some of these anterior pituitary hormones induce other glands to secrete their hormones. The increase in blood levels of the hormones produced by the final target glands (e.g., the ovary or thyroid) inhibits the release of anterior pituitary hormones. Changes in levels of pituitary hormones are discussed in the following paragraphs. FSH and LH secretion are inhibited during pregnancy, probably as a result of hCG produced by the placenta and corpus luteum, and the increased secretion of prolactin by the anterior pituitary gland. Levels remain decreased until after delivery. Thyroid-stimulating hormone (TSH) is reduced during the first trimester but usually returns to normal for the remainder of the pregnancy. Decreased TSH is thought to be one of the factors, along with elevated hCG levels, associated with morning sickness, nausea, and vomiting during the first trimester. Growth hormone (GH) is an anabolic hormone that promotes protein synthesis. It stimulates most body cells to grow in size and divide, facilitating the use of fats for fuel and conserving glucose. During pregnancy, there is a decrease in the number of GH-producing cells and a corresponding decrease in GH blood levels. The action



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of human placental lactogen (hPL) is thought to decrease the need for and use of GH. During pregnancy, prolactin is secreted in pulses and increases 10-fold to promote breast development and the lactation process. High levels of progesterone secreted by the placenta inhibit the direct influence of prolactin on the breast during pregnancy, thus suppressing lactation. At birth, as soon as the placenta is expelled and there is a drop in progesterone, lactogenesis can begin (Cunningham et al., 2010). Melanocyte-stimulating hormone (MSH), another anterior pituitary hormone, increases during pregnancy. For many years, its increase was thought to be responsible for many of the skin changes of pregnancy, particularly changes in skin pigmentation (e.g., darkening of the areola, melasma, and linea nigra). However, currently it is thought that the skin changes are due to estrogen (and possibly progesterone) as well as the increase in MSH. The two hormones oxytocin and antidiuretic hormone (ADH) released by the posterior pituitary are actually synthesized in the hypothalamus. They migrate along nerve fibers to the posterior pituitary and are stored until stimulated to be released into the general circulation. Oxytocin is released by the posterior pituitary gland, and its production gradually increases as the fetus matures (Simpson & Creehan, 2011). Oxytocin is responsible for uterine contractions, both before and after delivery. The muscle layers of the uterus (myometrium) become more sensitive to oxytocin near term. Toward the end of a term pregnancy, levels of progesterone decline and contractions that were previously suppressed by progesterone begin to occur more frequently and with stronger intensity. This change in the hormonal levels is believed to be one of the initiators of labor. Oxytocin is responsible for stimulating the uterine contractions that bring about delivery. Contractions lead to cervical thinning and dilation. They also exert pressure, helping the fetus to descend in the pelvis for eventual delivery. After delivery, oxytocin secretion continues, causing the myometrium to contract and helping to constrict the uterine blood vessels, decreasing the amount of vaginal bleeding after delivery. Oxytocin is also responsible for milk ejection during breast-feeding. Stimulation of the breasts through sucking or touching stimulates the secretion of oxytocin from the posterior pituitary gland. Oxytocin causes contraction of the myoepithelial cells in the lactating mammary gland. With breast-feeding, “after pains” often occur, which signals that oxytocin is being released. Vasopressin, also known as antidiuretic hormone (ADH) functions to inhibit or prevent the formation of urine via vasoconstriction, which results in increased blood pressure. Vasopressin also exhibits an antidiuretic effect and plays an important role in the regulation of water balance (Mattson & Smith, 2011).

PANCREAS The pancreas is an exocrine organ, supplying digestive enzymes and buffers, and an endocrine organ. The endocrine pancreas consists of the islets of Langerhans, which are groups of cells scattered throughout, each containing four cell types. One of the cell types is the beta cell, which produces insulin. Insulin lowers blood glucose by increasing the rate of glucose uptake and utilization by most body cells. The growing fetus needs significant amounts of glucose, amino acids, and lipids. Even during early pregnancy the fetus makes demands on the maternal glucose stores. Ideally, hormonal changes of pregnancy help meet fetal needs without putting the mother’s metabolism out of balance. A woman’s insulin secretion works on a “supply vs. demand” mode. As the demand to meet the needs of pregnancy increases, more insulin is secreted. Maternal insulin does not cross the placenta, so the fetus must produce his or her own supply to maintain glucose control. (Box 11.2 gives information about pregnancy, glucose, and insulin.)

BOX 11.2

PREGNANCY, INSULIN, AND GLUCOSE • During early pregnancy, maternal glucose levels decrease because of the heavy fetal demand for glucose. The fetus is also drawing amino acids and lipids from the mother, decreasing the mother’s ability to synthesize glucose. Maternal glucose is diverted across the placenta to assist the growing embryo/ fetus­during early pregnancy, and thus levels decline in the mother. As a result, maternal glucose concentrations decline to a level that would be considered “hypoglycemic” in a nonpregnant woman. During early pregnancy there is also a decrease in maternal insulin production and insulin levels. • The pancreas is responsible for the production of insulin, which facilitates entry of glucose into cells. Although glucose and other nutrients easily cross the placenta to the fetus, insulin does not. Therefore, the fetus must produce its own insulin to facilitate the entry of glucose into its own cells. • After the first trimester, hPL from the placenta and steroids (cortisol) from the adrenal cortex act against insulin. hPL acts as an antagonist against maternal insulin, and thus more insulin must be secreted to counteract the increasing levels of hPL and cortisol during the last half of pregnancy. • Prolactin, estrogen, and progesterone are also thought to oppose insulin. As a result, glucose is less likely to enter the mother’s cells and is more likely to cross over the placenta to the fetus Adapted from Cunningham, F. G., Levano, K. J., Bloom, S. L., Hauth, J. C., Rouse, D. J., & Spong, C. Y. (2010). William’s ­obstetrics (23rd ed.). New York, NY: McGraw-Hill.

346   U N I T 3   Pregnancy

During the first half of pregnancy, much of the maternal glucose is diverted to the growing fetus, and thus the mother’s glucose levels are low. hPL and other hormonal antagonists increase during the second half of pregnancy. Therefore, the mother must produce more insulin to overcome the resistance by these hormones. Insulin resistance in pregnancy is consequent to the physiologic adaptation necessary to provide glucose to the growing fetus. Disturbance in the maternal metabolism can induce structural and functional adaptations during fetal development (Power & Schulkin 2012). If the mother has normal beta cells of the islets of Langerhans, there is usually no problem meeting the demands for extra insulin. However, if the woman has inadequate numbers of beta cells, she may be unable to produce enough insulin and will develop glucose intolerance during pregnancy. If the woman has glucose intolerance, she is not able to meet the increasing demands and her blood glucose level increases. ADRENAL GLANDS Pregnancy does not cause much change in the size of the adrenal glands themselves, but there are changes in some secretions and activity. One of the key changes is the marked increase in cortisol secretion, which regulates carbohydrate and protein metabolism and is helpful in times of stress. Although pregnancy is considered a normal condition, it is a time of stress for a woman’s body. The rate of secretion of cortisol by maternal adrenals is not increased in pregnancy, but the rate of clearance is decreased. Cortisol increases in response to increased estrogen levels throughout pregnancy and returns to normal levels within 6 weeks postpartum (Abraham, 2011). During the stress of pregnancy, cortisol: • Helps keep up the level of glucose in the plasma by breaking down noncarbohydrate sources, such as amino and fatty acids, to make glycogen. Glycogen, stored in the liver, is easily broken down to glucose when needed so that glucose is available in times of stress. • Breaks down proteins to repair tissues and manufacture enzymes. • Has anti-insulin, anti-inflammatory, and antiallergic actions. • Is needed to make the precursors of adrenaline, which the adrenal medulla produces and secretes (Cunningham et al., 2010). The amount of aldosterone, also secreted by the adrenal glands, is increased during pregnancy. It normally regulates absorption of sodium from the distal tubules of the kidney. During pregnancy, progesterone allows salt to be “wasted” (or lost) in the urine. Aldosterone is a key regulator of electrolyte and water homeostasis and plays a central role in blood pressure regulation. Hormonal changes

during pregnancy, among them increased progesterone and aldosterone production, lead to the required plasma volume expansion of the maternal body as an accommodation mechanism for fetus growth. Aldosterone is produced in increased amounts by the adrenal glands as early as 15 weeks of pregnancy (Abdelmannan & Aron, 2011). PROSTAGLANDIN SECRETION DURING PREGNANCY Prostaglandins are not protein or steroid hormones; they are chemical mediators, or “local” hormones. Although hormones circulate in the blood to influence distant tissues, prostaglandins act locally on adjacent cells. The fetal membranes of the amniotic sac—the amnion and chorion—are both believed to be involved in the production of prostaglandins. Various maternal and fetal tissues, as well as the amniotic fluid itself, are considered to be sources of prostaglandins, but details about their composition and sources are limited. It is widely believed that prostaglandins play a part in softening the cervix and initiating and/or maintaining labor, but the exact mechanism is unclear. PLACENTAL SECRETION The placenta has a feature possessed by no other endocrine organ—the ability to form protein and steroid hormones. Very early during pregnancy, the placenta begins to produce the following hormones: • hCG • hPL • Relaxin • Progesterone • Estrogen Table 11.3 summarizes the role of these hormones.

Immune System The immune system is made up of organs and specialized cells whose primary purpose is to defend the body from foreign substances (antigens) that may cause tissue injury or disease. The mechanisms of innate and adaptive immunity work cooperatively to prevent, control, and eradicate foreign antigens in the body. A general enhancement of innate immunity (inflammatory response and phagocytosis) and suppression of adaptive immunity (protective response to a specific foreign antigen) take place during pregnancy. These immunologic alterations help prevent the mother’s immune system from rejecting the fetus (foreign body), increase her risk of developing certain infections such as urinary tract infections, and influence the course of chronic disorders such as autoimmune diseases. Some chronic conditions worsen (diabetes) while others seem to stabilize (asthma) during pregnancy, but this is individualized and not predictable. In general, immune function in pregnant women is similar to immune function in nonpregnant women.



C h a p t e r 1 1   Maternal Adaptation During Pregnancy    347

TABLE 11.3

PLACENTAL HORMONES

Hormone

Description

Human chorionic gonadotropin (hCG)

• Responsible for maintaining the maternal corpus luteum, which secretes progesterone and estrogens, with synthesis occurring before implantation • Production by fetal trophoblast cells until the placenta is developed sufficiently to take over that function • Basis for early pregnancy tests because it appears in the maternal bloodstream soon after implantation • Production peaks at 8 weeks and then gradually declines.

hPL (also known as human chorionic somatomammotropin [hCS])

• Preparation of mammary glands for lactation and involved in the process of making glucose available for fetal growth by altering maternal carbohydrate, fat, and protein metabolism

Relaxin

• Secretion by the placenta as well as the corpus luteum during pregnancy

• Antagonist of insulin because it decreases tissue sensitivity or alters the ability to use insulin • Increase in the amount of circulating free fatty acids for maternal metabolic needs and decrease in maternal metabolism of glucose to facilitate fetal growth

• Thought to act synergistically with progesterone to maintain pregnancy • Increase in flexibility of the pubic symphysis, permitting the pelvis to expand during delivery • Dilation of the cervix, making it easier for the fetus to enter the vaginal canal; thought to suppress the release of oxytocin by the hypothalamus, thus delaying the onset of labor contractions Progesterone

• Often called the “hormone of pregnancy” because of the critical role it plays in supporting the endometrium of the uterus • Supports the endometrium to provide an environment conducive to fetal survival • Produced by the corpus luteum during the first few weeks of pregnancy and then by the placenta until term • Initially, causes thickening of the uterine lining in anticipation of implantation of the fertilized ovum. From then on, it maintains the endometrium, inhibits uterine contractility, and assists in the development of the breasts for lactation.

Estrogen

• Promotes enlargement of the genitals, uterus, and breasts, and increases vascularity, causing vasodilatation. • Relaxation of pelvic ligaments and joints • Associated with hyperpigmentation, vascular changes in the skin, increased activity of the salivary glands, and hyperemia of the gums and nasal mucous membranes • Aids in developing the ductal system of the breasts in preparation for lactation

Adapted from Cunningham, F. G., Levano, K. J., Bloom, S. L., Hauth, J. C., Rouse, D. J., & Spong, C. Y. (2010). William’s obstetrics (23rd ed.). New York, NY: McGraw-Hill; Edelman, C. L., & Mandle, C. L. (2010). Health promotion throughout the lifespan (7th ed.). St. Louis, MO: Mosby Elsevier; and Shields, A. D. (2012). Pregnancy diagnosis. eMedicine. Retrieved from http://emedicine.medscape.com/article/262591-overview.

Marva returns for her first prenatal appointment and tells the nurse that her whole body is “out of sorts.” She is overwhelmed and feels poorly. Outline the bodily changes Marva can expect each trimester to help her understand the adaptations taking place. What guidance can the nurse give Marva to help her understand the changes of pregnancy?

Table  11.4 summarizes the general body systems’ adaptations to pregnancy.

CHANGING NUTRITIONAL NEEDS OF PREGNANCY Healthy eating during pregnancy enables optimal gestational weight gain and reduces complications, both of which are associated with positive birth outcomes.

TABLE 11.4

SUMMARY OF GENERAL BODY SYSTEM ADAPTATIONS

System

Adaptation

Gastrointestinal system

Mouth and pharynx: Gums become hyperemic, swollen, and friable and tend to bleed easily. Saliva production increases. Esophagus: Decreased lower esophageal sphincter pressure and tone, which increases the risk of developing heartburn Stomach: Decreased tone and mobility with delayed gastric emptying time, which increases the risk of gastroesophageal reflux and vomiting. Decreased gastric acidity and histamine output, which improves symptoms of peptic ulcer disease. Intestines: Decreased intestinal tone motility with increased transit time, which increases risk of constipation and flatulence Gallbladder: Decreased tone and motility, which may increase risk of gallstone formation

Cardiovascular system

Blood volume: Marked increase in plasma (50%) and RBCs (25–33%) compared to ­nonpregnant values. Causes hemodilution, which is reflected in a lower hematocrit and hemoglobin. Cardiac output and heart rate: CO increases from 30% to 50% over the nonpregnant rate by the 32nd week of pregnancy. The increase in CO is associated with an increase in venous return and greater right ventricular output, especially in the left lateral position. Heart rate increases by 10–15 bpm between 14 and 20 wks of gestation, and this increase persists to term. Blood pressure: Diastolic pressure decreases typically 10–15 mm Hg to reach its lowest point by mid-pregnancy; it then gradually returns to nonpregnant baseline values by term. Blood components: The number of RBCs increases throughout pregnancy to a level 25–33% higher than nonpregnant values. Both fibrin and plasma fibrinogen levels increase, along with various blood-clotting factors. These factors make pregnancy a hypercoagulable state.

Respiratory system

Enlargement of the uterus shifts the diaphragm up to 4 cm above its usual position. As muscles and cartilage in the thoracic region relax, the chest broadens, with conversion from abdominal breathing to thoracic breathing. This leads to a 50% increase in air volume per minute. Tidal volume, or the volume of air inhaled, increases gradually by 30–40% (from 500 to 700 mL) as the pregnancy progresses.

Renal/urinary system

The renal pelvis becomes dilated. The ureters (especially the right ureter) elongate, widen, and become more curved above the pelvic rim. Bladder tone decreases and bladder capacity doubles by term. GFR increases 40–60% during pregnancy. Blood flow to the kidneys increases by 50–80% as a result of the increase in cardiac output.

Musculoskeletal system

Distention of the abdomen with growth of the fetus tilts the pelvis forward, shifting the center of gravity. The woman compensates by developing an increased curvature (lordosis) of the spine. Relaxation and increased mobility of joints occur because of the hormones progesterone and relaxin, which lead to the characteristic “waddle gait” that pregnant women demonstrate toward term.

Integumentary system

Hyperpigmentation of the skin is the most common alteration during pregnancy. The most common areas include the areola, genital skin, axilla, inner aspects of the thighs, and linea nigra. Striae gravidarum, or stretch marks, are irregular reddish streaks that may appear on the abdomen, breasts, and buttocks in about half of pregnant women.

348



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TABLE 11.4

SUMMARY OF GENERAL BODY SYSTEM ADAPTATIONS (continued)

System

Adaptation The skin in the middle of the abdomen may develop a pigmented line called linea nigra, which extends from the umbilicus to the pubic area. Melasma (“mask of pregnancy”) occurs in 45–70% of pregnant women. It is characterized by irregular, blotchy areas of pigmentation on the face, most commonly on the cheeks, chin, and nose.

Endocrine system

Controls the integrity and duration of gestation by maintaining the corpus luteum via hCG secretion; production of estrogen, progesterone, hPL, and other hormones and growth factors via the placenta; release of oxytocin (by the posterior pituitary gland), prolactin (by the anterior pituitary), and relaxin (by the ovary, uterus, and placenta).

Immune system

A general enhancement of innate immunity (inflammatory response and phagocytosis) and suppression of adaptive immunity (protective response to a specific foreign antigen) take place during pregnancy. These immunologic alterations help prevent the mother’s immune system from rejecting the fetus (foreign body), increase her risk of developing certain infections, and influence the course of chronic disorders such as autoimmune diseases.

During pregnancy, maternal nutritional needs change to meet the demands of the pregnancy. Healthy eating can help ensure that adequate nutrients are available for both mother and fetus. Nutritional intake during pregnancy has a direct effect on fetal well-being and birth outcome. Inadequate nutritional intake, for example, is associated with preterm birth, low birth weight, and congenital anomalies. Excessive nutritional intake is connected with fetal macrosomia (>4,000 g), leading to a difficult birth, neonatal hypoglycemia, and continued obesity in the mother (Nodine & Hastings-Tolsma, 2012). Since the requirements for so many nutrients increase during pregnancy, pregnant women should take a vitamin and mineral supplement daily. Prenatal vitamins are prescribed routinely as a safeguard against a less-than-optimal diet. In particular, iron and folic acid need to be supplemented because their increased requirements during pregnancy are usually too great to be met through diet alone. With the exception of folic acid, there is little scientific evidence to support giving vitamin supplements to healthy pregnant women, but it seems to be a standard of care today (Nelson, 2011). Iron and folic acid are needed to form new blood cells for the expanded maternal blood volume and to prevent anemia. Iron is essential for fetal growth and brain development and in the prevention of maternal anemia. An increase in folic acid is essential before pregnancy and in the early weeks of pregnancy to prevent neural tube defects in the fetus. For most pregnant women, supplements of 30 mg of ferrous iron and 400 to 800 mcg of folic acid

per day are recommended by the dietary reference intakes (DRIs) (Institute of Medicine [IOM], 2010f; Ross et al., 2011; U.S. Preventive Services Task Force, 2010). Women with a previous history of a fetus with a neural tube defect are often prescribed a higher dose of folic acid. There is an abundance of conflicting advice about nutrition during pregnancy and what is good or bad to eat. Overall, the following guidelines are helpful: • Increase your consumption of fruits and vegetables. • Replace saturated fats with unsaturated ones. • Avoid hydrogenated or partially hydrogenated fats. • Do not consume any alcoholic beverages. • Use reduced-fat spreads and dairy products instead of full-fat ones. • Eat at least two servings of fish weekly, with one of them being an oily fish. • Consume at least 2 quarts of water daily (Ural & Booker, 2011). In the months before conception, food choices are key. The foods and vitamins consumed can ensure that the woman and her fetus will have the nutrients that are essential for the very start of pregnancy. While most women recognize the importance of healthy eating during pregnancy, some find it challenging to achieve. Many women say they have little time and energy to devote to meal planning and preparation. Another barrier to healthy eating is conflicting messages from various sources, resulting in a lack of clear, reliable, and relevant information. Moreover, many women are eating less in an effort to control their

350   U N I T 3   Pregnancy

weight, putting them at greater risk of inadequate nutrient intake.

Nutritional Requirements During Pregnancy Pregnancy is one of the most nutritionally demanding periods of a woman’s life. Gestation involves rapid cell division and organ development, and an adequate supply of nutrients is essential to support this tremendous fetal growth. Most women are usually motivated to eat properly during pregnancy for the sake of the fetus. The Food and Nutrition Board of the National Research Council has made recommendations for nutrient intakes for people living in the United States. The DRIs are more comprehensive than previous nutrient guidelines issued by the board. They have replaced previous recommendations because they are not limited to preventing deficiency diseases. Rather, the DRIs incorporate current concepts about the role of nutrients and food components in reducing the risk of chronic disease, developmental disorders, and other related problems. The DRIs can be used to plan and assess diets for healthy people (Dudek, 2010). These dietary recommendations also include information for women who are pregnant or lactating, because growing fetal and maternal tissues require increased quantities of essential dietary components. For example, the current DRIs suggest an increase in the pregnant woman’s intake of protein from 60 to 80 g/day, iron from 18 to 27 g/day, and folic acid from 400 to 800 mcg/day, along with an increase of 300 calories/day over the recommended intake of 1,800 to 2,200 calories/ day for nonpregnant women (IOM, 2010a, 2010b, 2010c, 2010d, 2010e, 2010f) (Table 11.5). For a pregnant woman to meet recommended DRIs, she should eat according to the U.S. Department of Agriculture (USDA) Food Guide MyPlate (Fig. 11.5). The Dietary Guidelines for Americans, 2010, are the basis for federal nutrition policy (USDA and U.S. Department of Health and Human Services [USDHHS], 2010). The Food Guide MyPlate provides guidance to help implement these guidelines. The USDA has designed an interactive online diet-planning program called the Daily Food Plan for Moms that helps pregnant women personalize their dietary intake throughfor additional out their pregnancy. (Refer to information about this food plan.) A summary of the new guidelines is as follows: • Eat a variety of food from all food groups using portion control. • Increase intake of vitamins, minerals, and dietary fiber. • Lower intake of saturated fats, trans fats, and cholesterol.

• Consume adequate synthetic folic acid from supplements or from fortified foods. • Increase intake of fruits, vegetables, and whole grains. • Balance calorie intake with exercise to maintain ideal healthy weight (USDA, 2011). The safety of artificial sweeteners consumed during pregnancy remains controversial. Some health care providers advise their pregnant clients to avoid all nonnutritive sweeteners during pregnancy, while others suggest they can be used in moderation (Dudek, 2010). The debate continues on this matter until additional research can be completed. An eating plan that follows the pyramid should provide sufficient nutrients for a healthy pregnancy. Except for iron, folic acid, and calcium, most of the nutrients a woman needs during pregnancy can be obtained by making healthy food choices. However, a vitamin and mineral supplement is generally prescribed.

Take Note! Good food sources of folic acid include dark green vegetables, such as broccoli, romaine lettuce, and spinach; baked beans; black-eyed peas; citrus fruits; peanuts; and liver. Fish and shellfish are an important part of a healthy diet because they contain high-quality protein, are low in saturated fat, and contain omega-3 fatty acids. However, nearly all fish and shellfish contain traces of mercury and some contain higher levels of mercury that may harm a developing fetus if ingested by pregnant women in large amounts. Human exposure to mercury occurs primarily through the consumption of fish contaminated through atmospheric mercury releases. The U.S. Environmental Protection Agency (EPA) and the United Nations Environment Program have identified coal-fired power plants as the source of 50% to 75% of the atmospheric mercury pollution in the United States and worldwide. Once airborne, rainfall transfers mercury particles into waterways where it is converted to the neurotoxic methylmercury form through a microbial process. Plankton absorbs the methylmercury and as the smaller fish eat the plankton and the larger predatory fish consume the smaller fish, the methylmercury bioaccumulates up the food chain to humans. All fish contain methylmercury regardless of the size or the geographic location of the waters from which the fish is caught, although size and type of fish as well as the geographic location of waters can influence lower or higher amounts of methylmercury. In addition, because methylmercury resides in the tissue of the fish, no method of cleaning or cooking will reduce the amount of mercury in a meal of contaminated fish (Geer, Persad, Palmer et al., 2012).



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TABLE 11.5

DIETARY RECOMMENDATIONS FOR THE PREGNANT AND LACTATING WOMAN

Nutrient

Nonpregnant Women

Pregnant Woman

Lactating Woman

Calories

2,200

2,500

2,700

Protein

60 g

80 g

80 g

Water/fluids

6–8 glasses daily

8 glasses daily

8 glasses daily

Vitamin A

700 mcg

770 mcg

1,300 mcg

Vitamin C

75 mg

85 mg

120 mg

Vitamin D

5 mcg

5 mcg

5 mcg

Vitamin E

15 mcg

15 mcg

19 mcg

B1 (thiamine)

1.1 mg

1.5 mg

1.5 mg

B2 (riboflavin)

1.1 mg

1.4 mg

1.6 mg

B3 (niacin)

14 mg

18 mg

17 mg

B6 (pyridoxine)

1.3 mg

1.9 mg

2 mg

B12 (cobalamin)

2.4 mcg

2.6 mcg

2.8 mcg

Folate

400 mcg

600 mcg

500 mcg

Calcium

1,000 mg

1,000 mg

1,000 mg

Phosphorus

700 mg

700 mg

700 mg

Iodine

150 mcg

220 mcg

290 mcg

Iron

18 mg

27 mg

9 mg

Magnesium

310 mg

350 mg

310 mg

Zinc

8 mg

11 mg

12 mg

Adapted from Institute of Medicine [IOM]. (2010a). Dietary reference intakes for calcium, phosphorus, magnesium, vitamin D and fluoride. Washington, DC: National Academy Press; IOM. (2010b). Dietary reference intakes for energy, carbohydrates, fiber, protein and amino acids. Washington, DC: National Academy Press; IOM. (2010c). Dietary reference intakes for thiamine, riboflavin, niacin, vitamin B6, vitamin B12, pantothenic acid, biotin, and choline. Washington, DC: National Academy Press; IOM. (2010d). Dietary reference ­intakes for vitamin A, vitamin K, arsenic, boron, chromium, copper, iodine, manganese, molybdenum, nickel, silicon, ­vanadium, and zinc. ­Washington, DC: National Academy Press; IOM. (2010e). Dietary reference intakes for vitamin C, vitamin E, selenium, and carotenoids. Washington, DC: National Academy Press; IOM. (2010f). Nutrition during pregnancy. Part I: Weight gain. Part II: Nutrient ­supplements. Washington, DC: National Academy Press; and Ural, S. H., & Booker, C. J. (2011). Prenatal nutrition. eMedicine. Retrieved from http://emedicine.medscape.com/article/259059-overview.

With this in mind, the FDA and the EPA are advising women who may become pregnant, pregnant women, and nursing mothers to do the following: • Avoid consumption of fish with moderate-to-high mercury levels (e.g., for 6 to 12 months prior to conception and throughout pregnancy). • Avoid eating shark, swordfish, king mackerel, orange roughy, ahi tuna, and tilefish because they are high in mercury levels. • Eat up to 12 ounces (two average meals) weekly of low-mercury-level fish such as shrimp, canned light tuna, salmon, pollock, and catfish.

• Check local advisories about the safety of fish caught by family and friends in local lakes, rivers, and coastal areas (Lando, Fein & Choiniere, 2012). Another food issue concern for pregnant women is consumption of food contaminated with the grampositive bacillus Listeria. Listeria is a type of bacteria found in soil, water, and sometimes on plants. Listeria is commonly found in processed and prepared foods and listeriosis is associated with high morbidity and mortality. Though Listeria is all around our environment, most Listeria infections in people result from eating

FIGURE 11.5 Food Guide for pregnancy.

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C h a p t e r 1 1   Maternal Adaptation During Pregnancy    353

contaminated foods. Listeriosis can be passed to an unborn baby through the placenta even if the mother is not showing signs of illness. This can lead to preterm births, miscarriages, stillbirths, and high neonatal mortality rates (Mattson & Smith, 2011). The Food Safety and Inspection Service and the FDA (2011) provide the following advice for pregnant women: • Do not eat hot dogs, luncheon meats, or deli meats unless they are reheated until steaming hot. • Avoid getting fluid from hot dog packages on other foods, utensils, and food preparation surfaces, and wash hands after handling hot dogs, luncheon meats, and deli meats. • Do not eat soft cheeses such as feta, Brie, Camembert, and blue-veined cheeses. • It is safe to eat hard cheeses, semi-soft cheeses such as mozzarella, pasteurized processed cheese slices and spreads, cream cheese, and cottage cheese. • Do not eat refrigerated pâté or meat spreads. • It is safe to eat canned or shelf-stable pâté and meat spreads. • Do not eat refrigerated smoked seafood unless it is an ingredient in a cooked dish such as a casserole. Examples of refrigerated smoked seafood include salmon, trout, whitefish, cod, tuna, and mackerel and are most often labeled as “nova-style,” “lox,” “kippered,” “smoked,” or “jerky.” This fish is found in the refrigerated section or sold at deli counters of grocery stores and delicatessens. • It is safe to eat canned fish such as salmon and tuna or shelf-stable smoked seafood. • Do not drink raw (unpasteurized) milk or eat foods that contain unpasteurized milk. • Use all refrigerated perishable items that are precooked or ready-to-eat as soon as possible. • Use a refrigerator thermometer to make sure that the refrigerator always stays at 40° F (about 5° C) or below. • Do not eat salads made in the store such as ham salad, chicken salad, egg salad, tuna salad, or seafood salad. • Clean your refrigerator regularly.

Maternal Weight Gain The amount of weight that a woman gains during pregnancy is not as important as what she eats. A woman can lose extra weight after a pregnancy, but she can never make up for a poor nutritional status during the pregnancy. Earlier guidelines recommended weight gain that would be optimal for the infant, but new guidelines take into account the well-being of the mother too (Table 11.6).

TABLE 11.6

NORMAL DISTRIBUTION OF WEIGHT GAIN DURING PREGNANCY

Component

Weight (pounds)

Infant birth weight

7.5

Blood volume increase

4

Uterus

2

Increase in breast tissue

2

Placenta

1.5

Maternal fluid volume

4

Maternal fat tissue

7

Amniotic fluid

2

Approximate total weight gain

30

Adapted from American College of Obstetricians and Gynecologists [ACOG]. (2011). Weight gain during pregnancy. Retrieved from http://pause.acog.org/president/weightduring-pregnancy; and Dudek, S. G. (2010). Nutrition essentials for nursing practice (6th ed.). Philadelphia, PA: Lippincott Williams & Wilkins.

The IOM (2009) and the National Research Council have issued recommendations for weight gain during pregnancy based on prepregnancy body mass index (BMI) as follows (Box 11.3): • Underweight (BMI < 18.5) total weight gain range = 28 to 40 pounds • Normal weight (BMI = 18.5–24.9) total weight gain range = 25 to 35 pounds • Overweight (BMI = 25–29.9) total weight gain range = 15 to 25 pounds • Obese (BMI = 30 or higher) total weight gain range = 11 to 20 pounds. Unfortunately, an estimated 40% to 73% of women gain weight outside of those ranges (Ural & Booker, 2011). A woman who is underweight before pregnancy or who has a low maternal weight gain pattern should be monitored carefully because she is at risk of giving birth to a low-birth-weight infant (1 in 25,000

No symptoms at birth. Most cases are identified before symptoms are present due to newborn screening (PKU is screened for in all states). If undiagnosed, newborn may present with vomiting, irritability, eczema-like rash, and mousy odor to urine.

Low-phenylalanine diet Phenylalanine is found mostly in proteincontaining foods such as meat and milk (including breast milk and formula). www.pkunetwork. org: Children’s PKU Network www.pkunews.org: National PKU News

Galactosemia: deficiency in the liver enzyme needed to convert galactose, the breakdown product of lactose, which is commonly found in dairy products, into glucose. Galactose accumulation leads to damage to vital organs.

>1 in 50,000

No symptoms at birth. If undiagnosed, newborn will have jaundice, diarrhea, and vomiting and will not gain weight. If untreated, can lead to liver disease, blindness, severe intellectual disability, and death.

Ingestion of galactose can produce sepsis in an affected child; therefore, septic workup and antibiotics may be necessary in a child if galactose ingestion has occurred. Elimination of galactose and lactose from the diet is the only treatment. Therefore, milk and dairy products will be eliminated for life. www.galactosemia.org: Parents of Galactosemic Children

Maple sugar urine disease: affects the metabolism of amino acids. A deficiency in the enzyme that metabolizes leucine, isoleucine, and valine, which are components of protein often referred to as the branch chain amino acids. These amino acids then accumulate in the blood and cause damage to the brain.

1 in 75,000

No symptoms at birth; in first weeks or months of life, symptoms such as hypotonia, uncoordinated movement, seizures, developmental delay, alopecia, seborrheic dermatitis, hearing loss, optic nerve atrophy, and intellectual disability develop. Metabolic acidosis can lead to death.

Daily oral free biotin http:// biotinidasedeficiency. 20m.com/: Biotinidase Deficiency Family Support Group

(continued)

1883

TABLE 51.7

INBORN ERRORS OF METABOLISM (continued)

Disorder/Explanation

Incidencea

Clinical Manifestations

Management

Medium-chain acylCoA dehydrogenase deficiency (MCAD): lack of an enzyme required to metabolize fatty acids

>1 in 25,000

Recurrent episodes of metabolic acidosis and hypoglycemia, lethargy, seizures, liver failure, brain damage, coma, and cardiac arrest. Can lead to serious and fatal illness in children not eating well

Avoid fasting; have frequent meals. Special considerations during illness. If unable to tolerate food, IV dextrose is required. www.fodsupport.org: Fatty Oxidation Disorders (FOD) Family Support Group

Homocystinuria: deficiency in the enzyme needed to digest a component of food called methionine (an amino acid)